NHSE and CQC criticised after new failings at Morecambe Bay

An external review into urology services at University Hospitals of Morecambe Bay Foundation Trust has identified 520 cases where patients suffered “actual or potential harm”, including several cases where patients died. It found systemic failings had contributed to the poor care.

The review, by consultancy firm Niche, has levelled multiple criticisms at the trust, but also said regulators and commissioners could have done more to help identify and address the problems.

It said NHS England and NHS Improvement were contacted directly by whistleblower Peter Duffy in 2016, but the chief executive’s office at NHSE “initially failed to respond and then redirected him to the Care Quality Commission”.

NHSE, whose chief executive at the time was Simon Stevens, said the message went to a corporate email address and was dealt with by the team managing the inbox in the normal way. It added: “At the time NHS England did not have a regulatory role and so the whistleblower was referred to CQC, GMC and NHS Improvement.”

Although NHSE/I’s regional team did seek assurance in 2017 that cases raised by Mr Duffy had been investigated, the review said they were “too easily reassured thereafter”.

The review said concerns about the problems had been raised anonymously with the CQC “on several occasions”, and the regulator was in contact with the trust, but it found “no evidence [the CQC] sought to examine the quality of investigations or test any of the cases in question”.

The CQC, which rated the trust as “good” in 2017, including for leadership, told HSJ in a statement: “We will reflect on the report in full to consider whether there is any specific action we may need to take as part of the ongoing work to develop CQC’s future regulatory approach.”

Earlier this year the trust’s leadership was rated “inadequate”, with an overall “requires improvement” rating for the organisation.

The Niche review was also critical of the General Medical Council, in terms of the “hugely extended timescales involved in responding to referrals” of individual consultants.

It said: “In one case it was four years before the GMC closed a patient’s family’s complaint, and currently a referral made in November 2017 continues four years later.

“We are also concerned that doctors are not informed of all complaints against them and nor are their employers (the GMC views some complaints raised to them as not requiring any action). As a result, there is no single perspective of the totality of concern of an individual doctor shared amongst all relevant stakeholders and the doctor themselves.

“Whilst we accept that at times referrals may need to be anonymous, this investigation is concerned by the level of vexatious reporting between consultant urologists. This has led to lengthy investigations which have been stressful for all concerned.”

The GMC said: “We will take forward action on the two points the Investigation has asked of us in its recommendations. This will include building on our intelligence-sharing work with other regulators to act on warning signs around dysfunctional teams more effectively, encouraging employers to make better use of the data we make available, and working with NHSE to strengthen the role of responsible officers.”

The review also criticised the quality assurance systems used by commissioners as being ineffective.

However, it recognised the “significant changes in commissioning structures over the last ten years have been a barrier to the embedding of effective governance and relationships with the trust” and warned “the continued fluidity with the emergence of the new integrated care system (ICS) and CCG reconfiguration may add distraction and create more distance between commissioners and frontline services”.

Morecambe Bay Clinical Commissioning Group said it would give “detailed consideration to each of the recommendations and will respond in due course”.