The Care Quality Commission (CQC) didn't properly investigate the circumstances of a five-year-old boy's death at a specialist centre for children with brain injuries, the Parliamentary and Health Service Ombudsman (PHSO) has found.
The Ombudsman is urging all regulatory health bodies to follow guidelines and act appropriately to make sure there is transparency and accountability when things go wrong in care.
The boy, who had neuro-disabilities, died during a six-week stay at a specialist centre for children with brain injuries. He had been doing well and had no significant underlying physical or medical concerns but was found dead in his cot on the morning of 17 May 2017. Based on the information it received from the Trust, the CQC initially believed the boy’s death was natural.
However, an inquest and Prevention of Future Deaths Report concluded that he died ‘following entrapment by a loose cot bumper causing death by way of airway obstruction’. A cot bumper is a padded panel placed around the inside of a cot to prevent injuries or falls.
The boy’s foster mother initially complained to the CQC but was not satisfied with its response and later brought her complaint to the Ombudsman.
The Ombudsman found that the CQC acted correctly based on the information it received immediately after the boy’s death. It also acted correctly in not pursuing criminal proceedings following the inquest as by law it can only do this within three years of the death occurring. The inquest did not conclude until 2022, five years after the boy’s death.
However, the Ombudsman found that the CQC should have considered taking enforcement action against the Trust when new information came to light before the inquest concluded. For example, when the CQC was informed that the coroner was considering death by negligence, and later, when it was told that the coroner was considering whether the cot bumper was instrumental in the boy’s death.
At that point, the events were still within the statutory timeframe.
By not examining the new information, the CQC missed the opportunity to assess the issues being raised and caused further stress and anxiety to the boy’s foster family.
The Ombudsman recommended the CQC apologise to the boy’s foster mother and create an action plan to improve its service to prevent the same mistake happening again. The CQC has complied with the recommendations.
Rebecca Hilsenrath, the Parliamentary and Health Ombudsman, said:
“This is a tragic case involving the death of a young boy who faced many challenges in his short life.
“His family have not only had to come to terms with a devastating loss but also the knowledge that those responsible for determining the circumstances of his death did not do all that they should have.
“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. Regulatory organisations 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 boy lived in Sheffield with his foster parents who had cared for him since he was six months old. His foster mother described him as happy boy who was full of energy, and loved dogs, football, and Paw Patrol.
His foster mother, a doctor, said:
“It was uncovered in the Ombudsman’s report that the CQC didn’t even hold a management review meeting after the adjourned inquest said that his death could have been caused by the bumper. That is the crux of the issue.
“It felt like the CQC just relied on what they were being told by the Trust without questioning it. The information being supplied by the coroner was ignored and all my attempts to contact the CQC were shut down. I was told we had to wait until the inquest was concluded, but by then it was too late for them to do anything.
“We’ve had no choice but to carry on with life, but it is very difficult because a big part of your life has gone. Trying to get answers and accountability for our boy has taken so much time and energy, it’s been a trauma in itself. Your trust in the organisations that you rely on to do the right thing is questioned and it leaves you feeling very vulnerable.
“You don’t believe anything like this can happen and I hope by bringing my case to the Ombudsman that no other family will have to go through this.
Read the case summary.