Regulator’s role in decision by ombudsman not to look into baby’s death is to be investigated

BMJ 2012; 345 doi: (Published 14 December 2012) Cite this as: BMJ 2012;345:e8524
  1. Clare Dyer
  1. 1BMJ

The Care Quality Commission has commissioned an independent review to investigate a claim that its former chief executive, Cynthia Bower, tried to discourage the health service ombudsman from investigating the death of a newborn baby at a hospital run by University Hospitals of Morecambe Bay NHS Trust.

The CQC has asked the consultancy firm Grant Thornton—which is already carrying out a review of its regulatory activities in relation to Morecambe Bay—to look into the allegations by the baby’s father, James Titcombe.

Joshua Titcombe died aged 9 days from a lung infection at Furness General Hospital, run by the Morecambe Bay trust, in November 2008. His is one of several deaths of babies and mothers at the hospital that are being investigated by Cumbria Police.1

James Titcombe asked the then parliamentary and health service ombudsman, Ann Abraham, to investigate his son’s death in early 2009. In February 2010 the ombudsman’s office wrote to him to say that it would not be investigating.

The primary reasons it gave were that the records of the first 24 hours of Joshua’s life were missing and that it was unlikely that an investigation would “reach a firm finding of what took place and why” and that the CQC had Morecombe Bay trust “closely under review.”

Titcombe has obtained documents under the Data Protection Act which, he says, show that Bower and Abraham discussed the case in the summer of 2009 and that Bower suggested that the ombudsman’s office need not investigate the death.

Among the documents is a memo written in September 2009 by deputy ombudsman Kathryn Hudson to Abraham. She wrote, “In your conversation with Cynthia Bower shortly before your leave, the suggestion arose that if we could assure Mr and Mrs Titcombe that as a result of their experiences CQC are now taking robust action to ensure improvements in the quality of maternity services in the trust, you might decide not to investigate.”

In a letter to the CQC’s head of operations, Amanda Sherlock, also in September 2009, Hudson wrote, “My understanding from Ann was that she discussed this very sad case with Cynthia in order to consider the best way of handling it. I had thought that Cynthia had suggested there might be a better way to deal with the issues involved through other assessments of the quality of the trust and the future of midwifery services in the North West.

“If this were the case we could consider declining to investigate but would want to be able to assure the family their concerns were being dealt with robustly in another way.”

In April 2010, two months after the ombudsman had decided not to investigate, the CQC registered Morecambe Bay trust without conditions, and Monitor, the regulator of foundation trusts, authorised foundation trust status later in 2010.

Titcombe kept trying to find out the facts about his son’s death, and eventually the coroner Ian Smith agreed to hold an inquest. In June 2011 the coroner said that Joshua, who had picked up an infection from his mother, would have had a 90% chance of survival if he had been given antibiotics immediately after his birth.

The coroner listed 10 failings by staff in what he described as “appalling” care and said that it was “not beyond the balance of possibility” that the baby’s observation sheet had been deliberately destroyed. After the inquest, Cumbria police launched its investigation. CQC and Monitor carried out inspections and found serious shortcomings, which an independent investigation by the consultancy firm KPMG found must have been present when the trust was approved by Monitor.2 3

Abraham, who is no longer ombudsman, and Bower, who resigned this year as chief executive of the CQC, referred the BMJ’s inquiries to their former press offices.

A CQC spokesman said, “CQC is clear that each organisation, as a statutory independent body, has to take its own decisions in respect of its functions. The investigation will look to establish how CQC made its decision.”

A spokesperson for the ombudsman said, “In this case, as always, the decision on whether to investigate is ours alone.”


Cite this as: BMJ 2012;345:e8524