Regulators failed to avert major failure of patient safety, report finds

A scathing report from Deloitte has found serious failings by regulators in stopping a major failure of patient safety at a London trust.

North Middlesex University Hospital (NMUH) saw major failures in patient safety between June 2014 and August 2016, starting with a CQC report in August 2014 that rated the hospital as ‘requires improvement.’

What followed over the next two years were a series of inspections, intelligence sharing meetings, risks summits, an extended round table (August 2015) and assurance meetings; concerning a range of issues such as higher mortality rates, CQC monitoring finding increased elevated risk, poor results in GMC trainee and CQC patient surveys, and concerns regarding anaesthetic and A&E trainees raised by Health Education England (HEE).

The failures in patient safety culminated in an undetected patient death on 13-14 December 2015 after the patient was reportedly left unattended for up to four-and-a-half hours.

Deloitte made a number of findings and recommendations in the report, including that the regulatory environment “did not promote a culture that incentivises open and honest behaviours,” and despite the fact that NMUH leadership should have been more open, the system should reflect on whether it has “the right balance” between support and assurance. 

The report also says that system stakeholders should recognise that there may be the need for re-inspection by the CQC where there are serious concerns and where the inspectorate has not responded directly, adding that HEE and GMC intelligence should form “an integral part” of CQC and NHSI intelligence monitoring, and that their concerns should have the same prominence as other regulators and arms-length bodies.

Other findings include that there was enough intel for the CQC in 2015 and that it had the opportunity to re-inspect before April 2016 but did not, bringing the inspectorates methods into question; that NHSI, NHSE and CCGs were too reliant on the CQC; that Quality Surveillance Groups were ineffective; and that, generally, the system with which the hospital was inspected and regulated was disjointed.

Dr Kathy McLean, executive medical director and chief operating officer at NHSI, commented: “The events at North Middlesex have important lessons for how oversight organisations work together to ensure that challenged trusts receive support to provide high quality care.

“Since the events at North Middlesex we have created the Joint Strategic Oversight Group where oversight organisations meet to share concerns, to ensure an aligned and consistent approach to supporting trusts and to intervening where necessary.

“Members include senior representatives from NHSI, NHSE, the CQC, HEE and the GMC.

“We are continually improving the way we work with other oversight organisations so that challenged trusts receive support quicker. We are creating seven integrated regional teams in the coming year which will take a more holistic view of the challenges faced by trusts and will proactively offer support to those that need it. The regional directors of these teams will play a major leadership role in the areas that they manage and will have full responsibility for quality, finance and operational performance of trusts in the region.”


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