CQC failed to investigate boy’s death properly

The PHSO finds that the CQC did not investigate the death of a five-year-old boy from brain injuries when new information came to light. 

The Parliamentary and Health Service Ombudsman (PHSO) has found that 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 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.

An inquest and Prevention of Future Deaths Report concluded that the boy 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.

A missed opportunity

The Ombudsman found that the CQC had acted correctly based on the information it received immediately after the boy’s death but 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.

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 from happening again. The CQC has complied with the recommendations.