• CQC had been investigating United Lincolnshire Hospitals Trust over handling of Elaine Bradbrook’s death
  • Decision comes despite coroner’s criticism of trust’s failure to investigate

The Care Quality Commission has dropped a prosecution against United Lincolnshire Hospitals Trust for duty of candour breaches due to a lack of evidence.

Despite a coroner criticising the trust’s failure to carry out an investigation or contact the family after a patient’s death, the CQC has confirmed it will not press ahead with legal action.

The watchdog had been investigating the Lincolnshire trust, which is in special measures, over its failure to investigate the death of a patient Elaine Bradbrook, who died in April 2017.

Meanwhile, the CQC had identified in earlier inspections a number of concerns around the governance and learning from incidents, including an inconsistent approach to following duty of candour rules.

Ted Baker, the CQC’s chief inspector of hospitals, told HSJ: “CQC is unable to pursue a prosecution case against United Lincolnshire Hospitals Trust due to insufficient evidence. Should further evidence come to light, it will be reviewed and consideration given to whether the investigation needs to be reopened.

“In response to the coroners findings, we followed up directly with the trust to ensure they had taken action to meet their responsibilities in line with the duty of candour and to request evidence of the wider action being taken to strengthen duty of candour processes and mitigate future risks to patient safety.

“The trust remains in special measures and subject to close monitoring.”

Elaine Bradbrook

In August last year, coroner Heidi Connor said the care of Ms Bradbrook, who died in April 2017 after suffering a stroke, “raised serious concerns about the management at Lincolnshire”.

She said she was surprised the trust had not carried out an investigation, adding: “The trust appears not to have appreciated the significance of these issues. It has not carried out any internal investigation, nor contacted Elaine’s family in line with its duty of candour.

“I am concerned that there has been no opportunity for learning within the trust, following these serious failures.”

Ms Bradbrook was admitted to the trust’s Pilgrim Hospital after a stroke, but the coroner found staff failed to properly observe her and raise the alarm when she deteriorated.

When an ambulance crew came to transfer her to Nottingham University Hospital as an emergency, the coroner said: “Elaine was handed to ambulance staff for transfer in a very deep coma, without protection of her airway, without escort, and without review by an anaesthetist or indeed any other doctor, after her deterioration on the afternoon of 22 April.”

The coroner added it was likely hospital staff knew the ambulance technician and trainee were not capable of intubating her.

Surgeons at NUH were said to be surprised by her condition when the ambulance arrived. Despite surgery, she suffered “massive brain swelling” and died on 27 April 2017.

The inquest

One Lincolnshire consultant required to give evidence booked a holiday after his summons to the inquest, but, despite rebooking the flight to the second day, asked to leave the hearing early after giving his evidence. There was then no one else present from the trust.

The coroner said: “The trust has confirmed (when we asked them) that there has been no internal investigation of these matters. The trust adduced no evidence of either an awareness of the issues arising from this inquest, nor any steps to reduce the risk for similar patients in future.”

She said it was surprising doctors had not been supported by the trust at the inquest “and that the trust has not investigated the circumstances of this case before now. The trust has a duty of candour, which appears to have been overlooked.”

United Lincolnshire medical director Neill Hepburn said: “We would like to apologise to Elaine Bradbrook’s family for the distress caused where the care we provided fell below the standard we would expect.

“We accept that some of our processes around duty of candour were not as robust as they should have been. In recent months, our performance has improved dramatically and in July 2019 our performance was 96 per cent in person and 88 per cent written.

“We take learning from incidents seriously, and our performance in terms of timeliness and quality have improved significantly in recent months. All serious incidents are reviewed and reported in a timely fashion with learning clearly identified. Reports are shared with the families if they wish.

“We also now have a medical examiner service in place and are working towards extending it to include all deaths. This means families will be contacted to explain what has happened and to raise any concerns. Our improved performance around safety has been reflected in our HMSR moving to the best quartile in the country.”


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