The NHS ombudsman has sharply criticized the Care Quality Commission (CQC) for its failure to properly investigate the death of a five-year-old boy who was living in a specialist residential unit. This marks a significant blow to the credibility of the CQC, which has already come under scrutiny in recent months. The incident highlights serious concerns about transparency and accountability within the care sector, with the boy’s foster mother accusing the care provider of orchestrating a cover-up of his death. The case also brings into question the role of child death investigations and whether regulators like the CQC are equipped to ensure thorough accountability.
What Are the Foster Mother's Alleged Cover-Up Claims?
According to the boy’s foster mother, who works as an NHS doctor, the Children’s Trust, the organization in charge of the boy’s care, purposefully withheld information about his passing. She alleges that the Care Quality Commission ignored substantial evidence that surfaced during the inquiry into her son’s death and that her efforts to learn the truth were thwarted.
“The CQC should have been much more curious. As a doctor, I’m used to dealing with the CQC. But I have lost trust in an organization that should be doing its utmost to make sure that places that look after vulnerable people are safe. They didn’t see that things weren’t adding up here,” the foster mother stated, expressing her anger over the lack of thorough investigation by the regulator.
How Did the Boy Die, and What Did the Inquest Find?
The boy, whose identity has not been disclosed, had neuro disabilities and had lived with his foster parents in Sheffield since he was six months old. Tragically, he was found dead in his cot one morning in May 2017, just six weeks after being placed in a specialist children’s home in Tadworth, Surrey, run by the Children’s Trust.
Initially, the CQC believed his death had been due to natural causes, based on the information provided by the charity. However, an inquest later revealed the actual cause of death was suffocation. The loose padded bumper in the boy’s cot, intended to prevent falls or injuries, had become dislodged and was found wedged under his neck, causing airway obstruction and resulting in his death.
The inquest concluded that the boy died “following entrapment by a loose cot bumper causing death by way of airway obstruction.” The CQC, despite this finding, failed to re-evaluate its stance or take further action in the child death investigation, which raised concerns about the regulator’s commitment to accountability.
Why Did the CQC Fail to Act on the Evidence from the Inquest?
The ombudsman pointed out that the Care Quality Commission failed to act on the emerging evidence from the inquest that cast doubt on the trust’s version of events. “Regulatory organizations must make sure they examine all the available evidence to uncover the truth for everyone involved and to prevent others from experiencing the same trauma,” the ombudsman stated.
The ombudsman’s criticism is significant, given that the CQC is responsible for ensuring care providers are held accountable when mistakes are made. In this case, the ombudsman noted that the lack of transparency and accountability added unnecessary pain and distress to the grieving family.
“When things go wrong in care, there should be accountability and lessons must be learned. If that doesn’t happen, grieving families suffer the added pain of having to fight harder to get the answers they’re looking for,” the ombudsman added.
What Did the Coroner’s Report Reveal About the Trust’s Case Handling?
The coroner who presided over the inquest also expressed concern about the lack of transparency in how the trust handled the boy’s death. The coroner issued a “prevention of future deaths” report, a legal warning to ensure that similar incidents do not occur again.
The report highlighted several issues, including the fact that police and coronial staff who attended the trust shortly after the boy’s death were not fully informed of the circumstances. For example, they were not told the position the boy’s body had been found in or that he had been dead for some time before being discovered. The coroner’s report also noted that the bumper had been seen across the boy’s neck, yet the trust had not informed relevant authorities of these crucial details.
The coroner remarked that the Children’s Trust had “not acknowledged there was a lack of transparency and openness into how [the boy] died or that the trust did not properly investigate his death or inform the relevant statutory bodies of the circumstances of his death.”
How Did the Children’s Trust Respond to the Coroner’s Findings?
Following the inquest, the Children’s Trust apologized to the boy’s family and accepted the coroner’s findings. The trust stated that it had already implemented new safety measures, such as new beds and cots, and had revised its overnight monitoring policy.
“Our senior leadership team has established an action group dedicated to developing new processes and systems that will address the coroner’s concerns,” the trust’s statement read. “This is in addition to measures we had already put in place in the last five years since [the boy’s] death; including new beds and cots, and changes to our overnight monitoring policy.”
Why Does the Foster Mother Continue to Feel Anger and Disbelief?
The foster mother, still grieving over the loss of the boy she had cared for since infancy, spoke about her continued frustration with the lack of accountability. She firmly believes that the Children’s Trust had a responsibility to be open and transparent about what happened and that the Care Quality Commission failed to hold them to account.
“I think there’s no doubt that there’s been a cover-up [by the trust]. I feel really angry. I feel like [her son’s] life didn’t matter,” she said, emphasizing that the CQC’s failure to investigate correctly had compounded her grief.
What Steps Has the CQC Taken in Response to the Findings?
In response to the ombudsman’s findings, the CQC acknowledged that the regulator had failed the boy’s family.
“Everyone has the right to expect safe, high-quality care and a regulator that they can trust to act in their and their loved one’s interest. We fell short in this case and we are deeply sorry for the impact this has had on this young boy’s family,” the CQC stated.
The criticism of the CQC and the revelations about the Children’s Trust’s handling of the boy’s death have raised important questions about the need for greater transparency and accountability in the care sector, mainly when vulnerable children are involved. This case serves as a stark reminder of the importance of child death investigations and ensuring that families get the answers they deserve.
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