• Report finds uncoordinated response from regulators meant a chance to stop a patient care scandal was missed
  • Care Quality Commission could have acted sooner on concerns
  • Health Education England report showing safety problems was not given sufficient “weight”

Disjointed regulators failed to prevent a major patient safety failure over winter, a new report reveals.

A Deloitte report into the system response to care failings at North Middlesex University Hospital’s accident and emergency services in 2015 found:

  • The Care Quality Commission could have re-inspected sooner than it did to address problems
  • Concerns from junior doctors were slow to be acted on by other bodies because Health Education England was considered a lightweight organisation
  • Regulators “did not promote a culture that incentivises open and honest behaviours”

The report said “the system was presented with a significant opportunity to address quality issues at NMUH but did not take it”.

In one incident in December 2015, a patient was found dead in a corridor at the hospital having been unattended for up to four-and-a-half-hours. Understaffing also saw up to 20 patients treated in corridors, a patient left on a bedpan for an hour and one commode being shared between 100 patients, the CQC found.

Deloitte said the Trust Development Authority “in particular” should have taken stronger action, as well as the CQC and NHS England.

It added: “We recognise that there were resource constraints at the TDA but, in our view, there was also a lack of appetite to tackle the issues.”

TDA chief executive David Flory retired in May 2015, when finance director Bob Alexander took over on an interim basis. Throughout 2015, the TDA was in the process of joining with Monitor to form NHS Improvement.

The report did not examine the trust’s role in the care failings but said it did “have a tendency to understate the full extent of the issues and there were opportunities for the trust to have been more open and transparent”.

It added: “However, the regulatory environment is considered by many interviewees to be assurance based and unsympathetic towards failing organisations. This has in-turn created a culture and operating environment that is not conducive to promoting open and honest discussions between providers and regulators.”

The CQC had rated the trust’s A&E as requires improvement in August 2014 and did not re-inspect until April 2016.

Between these visits Health Education England and the General Medical Council were the main external organisations to “directly access ‘sentiment’ on the frontline of the emergency department at the trust”.

A joint team found that 15 of the 18 trainees working in A&E reported having to deal with situations beyond their competence without appropriate supervision on a regular basis.

The Deloitte report said: “This intelligence did not gain sufficient prominence. This was partly due to HEE not having the same status as other organisations”.

The report also criticised the TDA and NHS England for not recognising there were times they needed to formally request a re-inspection by the CQC.

The re-inspection took place after HEE chief executive Ian Cumming wrote directly to CQC chief executive David Behan.

Deloitte said the situation “further highlighted challenges” with the TDA being understaffed, and that this weakness worsened the confusion over roles and responsibilities between them and NHS England.

It said NHS England “assumed the lead role in the context of resilience planning, [and] there are numerous accounts from interviewees that this arrangement was also influenced by resourcing constraints at NHSI and ‘strong characters’ at NHSE.”

NHS England’s London chief executive at the time was Anne Rainsberry and its medical director was Andy Mitchell. NHS England declined to comment on this article.

The Deloitte report was commissioned in March 2017, completed in December, and released yesterday.

NHS Improvement said changes to the regulatory system had been brought in since the problems at NMUH. HSJ reported last week that HEE will report directly to NHS Improvement under a new system currently being designed.

In a statement NHSI’s executive medical director and chief operating officer Kathy McLean said: “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.

“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.”

“Joint strategic oversight groups”, which include representatives from NHS Improvement, NHS England, the Care Quality Commission, Health Education England and the General Medical Council were set up in May 2017.

The regulator has not however adopted the report’s recommendation for appointing independent chairs to cross-system forums. Deloitte said this would “ensure that the outcome is based on the available information and not influenced by pressures facing individuals and their respective organisations.”

The CQC’s chief inspector of hospitals Ted Baker said the regulator had worked closely with NHS improvement, and developments like the new emerging concerns protocol should help in the future.

The CQC’s budget is due to fall 12.9 per cent from its 2015-16 level (£249m) by the end of next year.

HEE said the report had recognised its “key role” in “protecting trainees and patients”.