Families condemn 'rotten' NHS cover-up over 16 baby deaths at Morecambe Bay as data protection stops culprits being named



Health Secretary Jeremy Hunt under pressure to name staff responsible



Inspection by CQC gave Morecambe Bay hospitals all-clear in 2010



CQC official produced a dossier showing the inspection was flawed

But bosses told him to destroy it to protect commission's reputation

Ministers and CQC blame data protection laws for names staying secret

Lib Dem MP Tim Farron calls for police to investigate the alleged cover-up







Health Secretary Jeremy Hunt was repeatedly challenged in the Commons over why the managers responsible for the cover-up will not be named

Health Secretary Jeremy Hunt today came under growing pressure to name and shame the NHS bosses responsible for covering up their failure to investigate a hospital where up to 16 babies died through neglect.

A damning report into failures at the Care Quality Commission was published today but without naming anyone responsible.

Mr Hunt insisted advice from government lawyers meant revealing the identities of the officials would breach data protection laws, to the fury of the families of the children who died.

MPs lined up to demand the names be made public, with Mr Hunt insisting he had 'no interest' in protecting the identities of those responsible but legal advice to the CQC had prevented publication.



Despite multiple warnings about Morecambe Bay hospitals, a CQC inspection gave the trust the all-clear in 2010.

Even when a CQC official produced a dossier showing the inspection was flawed, bosses told him to destroy it to protect the commission’s reputation.

In the accounts of a discussion between officials about what to do with the findings one senior manager said: ‘Are you kidding me? This can never be in the public domain nor subject to a freedom of information request – read my lips.’

But the CQC has insisted a damning report into the scandal today should contain no names – so individuals can escape blame.

James Titcombe, whose son Joshua died aged just nine days old after staff failed to spot and treat an infection, condemned the decision to insist on anonymity.

He said: ‘There are questions about whether that reflects the direction the NHS should be going in, in terms of openness and transparency.’

Mr Titcombe added that the revelations of a cover-up laid bare the need for a major change in the health service.

He told Sky News: ‘It embodies everything that is wrong with the culture in the NHS. It's something that's been rotten really about the system. We need it to change. We need that culture to change.

‘Patient safety should be the number one priority, and organisations that work within regulation need to be aligned with that principle.’

Problems: Despite multiple warnings about Morecambe Bay hospitals (based at Westmorland General Hospital in Kendal, Cumbria - pictured), a Care Quality Commission inspection gave the trust the all-clear in 2010 The CQC – the official watchdog for hospitals, care homes, GP practices and dentists – has also been accused of failing to spot the appalling neglect at Mid-Staffordshire hospital and the horrific abuse of disabled patients at Winterbourne View hospital. Today’s report lists a series of failures in its oversight of University Hospitals Morecambe Bay. As well as up to 16 babies, two mothers are now thought to have died there because of poor care between 2002 and 2011. Mr Hunt was called to the House of Commons today to give an emergency statement on the appalling failings. He told MPs: ‘What happened at Morecambe Bay Hospital is, above all, a terrible personal tragedy for all of the families involved. ‘Before saying anything else I want to apologise on behalf of the government and the NHS for all the appalling suffering they have endured. ‘In that context I know the whole House will wish to extend our condolences to every one of them.’ He said there had been a ‘completely unacceptable attempt to cover up the deficiencies at the CQC’. Tragic baby Joshua Titcombe bled to death nine days after his birth in October 2008 at Furness General Hospital Mr Hunt told MPs that new CQC boss David Prior will now report to him on further action to be taken by the commission, including possible ‘internal disciplinary procedures and other appropriate sanctions’. He said: ‘The whole truth must now come out and individuals must be held accountable for their actions.’ But MPs from all parties demanded he ignore the legal advice and name the officials responsible for the cover-up. Labour’s Andy Burnham urged the government to review the rules on data protection. He added: ‘Given that accountability is essential… people will find it hard to accept if data protection laws stand in the way of that.’ He asked Mr Hunt to ‘review the decision to shield the identities of those involved’. Labour former culture secretary Ben Bradshaw said the Data Protection Act provided clear exemptions when it comes to 'protecting members of the public from dishonesty, malpractice, incompetence or seriously improper conduct, or in connection with health and safety'. Mr Bradshaw added: 'Will you please challenge the CQC interpretation of the Act and if necessary ask the Information Commissioner to rule on this flawed decision?' But Mr Hunt replied: 'I can reassure you that neither the chairman of CQC, nor I, have any interest whatsoever in keeping these names secret. 'He did receive legal advice telling him that he couldn't publish them (the names). But I will go back to him and tell him what you say and I know that he would like to be as transparent as possible. 'The choice he had on the basis of the legal advice was either not to publish the report or to publish it without the names and I think he took the right decision, given the advice that he had.'



Baby Amelia Jade Bower died the day she was born at Furness General Hospital

Kelly Hine told how in 2011, her newborn baby Amelia Jade Bower died in Furness General Hospital after inhaling meconium, the waste product newborn babies produce

Lib Dem Tim Farron, whose Westmorland and Lonsdale constituency is served by Morecambe Bay, said the report suggested an ‘appalling failure’ by the CQC.

He has called on the Met Police to launch an investigation into alleged criminal behaviour.



In a letter to Commissioner Sir Bernard Hogan-Howe, he wrote: 'I believe this information that has come to light today could be prima facie evidence that an offence has been committed.

'I urge you to proceed with an investigation using the evidence available.'

Speaking earlier Mr Farron said: 'What the report today demonstrates is that it would appear that there was a deliberate suppression of facts that, had they come to light, could have saved lives.

‘That is bordering on criminal and we need to look at whether it was criminal.’

Labour MP John Woodcock said: ‘The regulator is supposed to expose health failings on behalf of patients, not suppress them. This evidence of a cover-up at the CQC is a stain on our health service.’

Downing Street said the cover-up was ‘deeply disturbing and appalling’.

David Prior, new chairman of CQC, today defended the secrecy: He said: ‘If we had published the names we would have been in breach of the Data Protection Act and open to being sued.

'We had to make the decision to either publish the report with the names redacted, or keep it private.’

He admitted the Morecambe scandal was 'a shocking state of affairs' and he was 'desperately sorry' for what had happened.

He said the commission had failed to investigate hospitals properly, telling BBC Radio 4: 'We were sending in people with a background in social care or police work to investigate a maternity unit.

'We were given assurances about a problem that were not backed up by expert inspections.

‘There’s an old saying ‘the fish rots from the head’ – the board and the executive were totally dysfunctional. The senior leadership team failed at the CQC and they’ve all gone.



'They’ve now all gone and there were no pay offs or anything like that.’

Downing Street said the failings at Furness General Hospital were 'deeply disturbing and appalling'

Outraged parents said the commission’s repeated failings raised serious questions about its ability to learn from its mistakes.

Concerns were first raised in September 2008 when Alex Davy-Brady died after becoming strangled in his mother’s umbilical cord. Two months later, Joshua Titcombe, who was nine days old, died from an infection that should have been treated with antibiotics.

Following the two cases, the parents of babies who had either died at the unit or suffered serious medical harm began launching legal claims.

'Are you kidding me? This can never be in the public domain nor subject to a freedom of information request – read my lips' What senior manager said in accounts of discussion between officials about what to do with findings

An internal review published in March 2010 highlighted concerns about the maternity unit, including poor training of midwives and a ‘dysfunctional’ relationship between staff.

The CQC did not read the report, and later that year inspected the trust – including the maternity unit – passing it as ‘safe’.

Concerns over maternity care continued to grow however, prompted by the inquest into Joshua’s death and, in June 2011, a police investigation was launched.

This led to serious questions as to why the CQC’s 2010 inspection passed the unit as safe. In March last year, one of the CQC’s officials – named only as ‘Mr J’ in today’s report – produced a document revealing a string of failings in the 2010 inspection.

But he was ordered to delete the revelations. Today’s report reads: ‘He informed us that he was instructed by a member of senior management at CQC to “delete” the report of his findings.



‘The individual claimed what laid behind the instruction to him to delete his report was a sense that it contained findings that were potentially damaging to CQC’s reputation. We have concluded on balance the evidence suggests it might well have constituted a “‘cover up”.’

The report does not shed light on who was responsible because the CQC has asked management consultancy firm Grant Thornton to keep all names out of it.

CUMBRIA POLICE QUIETLY DROP INQUIRY INTO ALL BUT ONE DEATH Cumbria police last week quietly dropped its criminal investigation into all but one of the 16 baby deaths at Furness General Hospital last week. The force's Major Investigation Team had been leading an 'extremely complex' police inquiry into Furness General Hospital's Maternity Unit since March 2011. It was launched before the inquest into Joshua Titcombe's death when officers received complaints about the standards of care Joshua received. However, on Friday - just days before the publication of a damning report into the Care Quality Commission's cover-up of the NHS trust running the hospital - Cumbria Constabulary issued a short statement saying that it had drastically scaled down its investigation. It means the other families of up to 15 babies who may have died because of failings at the Morecambe Bay hospitals trust will not see those responsible face criminal action.

Joshua's death is still being investigated by detectives. Detective Inspector Doug Marshall said: 'The investigation into the complaints received about Furness General Hospital Maternity Unit has been extremely complex. 'The investigation into the death of Joshua Titcombe is continuing. 'In respect of the other complaints we have received in the course of that investigation we have been able to inform those family members that their cases will not proceed to a criminal prosecution. 'The families have been provided with information on how to progress their concerns with the Trust and a number of investigations involving other regulatory bodies are ongoing. '





The report also concludes the CQC ‘did not apply an appropriate degree of professional scepticism’ when assessing the trust, and displayed poor governance, ‘questionable’ decision-making and bad communication’.

Staff at the regulator had a ‘register now – check later’ philosophy and relied too much on the trust’s own assessment of itself.

Some of the failings over Morecambe Bay – which had the highest mortality rate of any trust in England in 2011 – indicated ‘systemic issues’ within the CQC which ‘may be worthy of further reflection by the Department of Health’.

Today’s report was commissioned only after complaints by bereaved parent James Titcombe, whose baby son Joshua died in Furness General Hospital after blunders from staff.

Last night Mr Titcombe said: ‘There should be serious questions as to why it is anonymised.

‘It lacks the transparency and the accountability that the NHS claims it is embracing and that is wrong.

‘If this is happening in Morecambe Bay, how are the CQC acting in the wider NHS? Who else knew about the cover up? Who else knew about the serious failures of the CQC?

‘Mothers and babies remained at risk for years. Mortality rates rocketed. The failure of the CQC cost lives and the trust is still failing to put it right.’

Kay Sheldon, a non-executive director at the CQC, had raised concerns about the inspection that took place at Morecambe Bay, but says she was ignored and ‘victimised’ by bosses for doing so.

Yesterday she said she felt vindicated, adding: ‘There was a catalogue of failures and they tried to cover it up. It’s outrageous.’

The CQC has also been dogged by scandals over claims that bosses have silenced whistleblowers, bullied staff and wasted taxpayers’ money on junkets and meals while failing to carry out enough inspections to keep patients safe.

Last year both the chief executive, Cynthia Bower, and chair, Dame Jo Williams, resigned over accusations they had presided over a culture of bullying and bureaucracy.

Even the organisation’s own employees have publicly warned it is so badly run it would miss scandals on the scale of Winterbourne View or the Mid Staffordshire hospital disaster.

Miss Sheldon added: ‘I suspect that there are other cases where the CQC has acted in a similar way as this report highlights.

‘In this case, what the CQC really didn’t want was another trust which was potentially as bad as Mid Staffs. The CQC didn’t consider that all of this was about public safety – all they cared about was their own reputation.’

She added: ‘The CQC have been trying to get rid of me ever since I gave evidence at the Mid Staffs enquiry in 2011. I tried to raise my concerns appropriately and in return I was victimised.

‘I have been persecuted because I was a whistleblower. They even had a mental health report done on me without my knowledge. They questioned my mental health, my conduct and my integrity. They considered suspending me because of the concerns I raised.’

The report – entitled Project Ambrose – comes two days after Morecambe Bay’s chief nurse Jackie Holt quit her role.

Tracey Morris at Furness General Hospital, where her sister-in-law Nittaya Hendrickson and newborn nephew Chester died

Chief executive Tony Halsall left in March with a £225,000 pay-off. A string of senior staff at the trust have ‘stepped down’ from their jobs with lucrative pay packets – but nobody has been sacked.

Thirty families are reported to be taking legal action against the trust over mother and baby deaths and cases of cerebral palsy. The CQC was set up in 2009 to take on the roles of three health quangos in England.

Last night, a CQC spokesman said: ‘This report reveals just how poor the Care Quality Commission’s oversight of University Hospitals Morecambe Bay was in 2010.

'This is not the way things should have happened. It is not the way things will happen in the future. We will use the report to inform the changes we are making to improve the way we work and the way we are run.

‘We are changing the culture of the organisation. The commissioning and publication of this report symbolises the approach we are taking and will continue to take. We are determined CQC will be an open and transparent organisation.

‘The report shows how CQC provided false assurances to the public and to Monitor in 2010. We were slow to identify failings at the trust and then slow to take action. We should not have registered UHMB without conditions. We let people down, and we apologise for that.’

The CQC’s chair David Prior added: ‘CQC’s chief executive David Behan was absolutely right to commission an independent report into CQC's handling of the registration and subsequent monitoring of UHMB - and absolutely right to publish it in full.

'The publication draws a line in the sand for us. What happened in the past was wholly unacceptable. The report confirms our view that at a senior level the organisation was dysfunctional. The board and the senior executive team have been radically changed.’

This insult to our baby's memory: Lives would have been saved if we had been listened to, says father



James Titcombe's baby son Joshua died at hospital in Barrow, Cumbria

Says Care Quality Commission had ignored his pleas for an investigation

Regulator gave hospitals clean bill of health after inspection two years on

This was despite concerns raised about poor care on the maternity unit



Vindicated: James Titcombe and wife Hoa pleaded for an investigation after Joshua's death

The lives of at least two babies could have been saved had the healthcare watchdog investigated a scandal-hit hospital properly, it was claimed last night.



James Titcombe, whose son Joshua was one of 16 babies thought to have died unnecessarily at Barrow-in-Furness general hospital, said the Care Quality Commission had ignored his pleas for an investigation.



Two years later, the regulator inspected the hospitals and gave them a clean bill of health, despite the concerns Mr Titcombe and others had raised about poor care on the maternity unit.



A damning report today revealed the CQC’s 2010 inspection was inadequate. It also states that bosses may have tried to cover up this fact by demanding that key evidence about the inspection’s failings be deleted.



Police have investigated the deaths of up to 16 babies at the same unit.



Two of those deaths occurred after the CQC’s 2010 inspection – and Mr Titcombe believes they could have been avoided if the CQC had investigated properly in the first place. He said yesterday:



‘We’ve been campaigning since Joshua’s death and we’ve slowly discovered that the problem spread much wider than just our case.



‘We couldn’t get anyone to investigate. There must be thousands of other people in the same situation as us.



‘The NHS is rotten to the core. The last few years have been a nightmare and it’s been hard to balance this campaign with my life.



‘What we wanted is for lessons to be learned by Joshua’s death.



‘But the same systematic problems that led to Joshua’s death went on and on. It was a missed opportunity and babies died as a result.’



Joshua bled to death at Furness General Hospital when he was nine days old following a series of blunders.



Blunders: Joshua Titcombe, who died at nine days, with sister Emily

His death – which was needless and ‘horrible’ – was the result of a common infection which he picked up from his mother and which could have been cured by antibiotics.



Mr Titcombe and his wife Hoa, 36, said they urged staff to treat Joshua with antibiotics but they were told he seemed well and did not need to see a doctor.



The project manager, who has two daughters, said they were told the paediatrician was ‘too busy’ to deal with them.



Eventually, the baby was so ill that he had to be airlifted to two other hospitals and he later bled to death when the infection spread to his lungs and caused a haemorrhage.



In 2011, an inquest into the tragedy found that Joshua’s medical notes may have been deliberately destroyed to cover up mistakes.



The coroner concluded that there were a number of ‘missed opportunities’ to save Joshua’s life in 2008 and his parents believe he would still be alive had he received proper care.



The inquest sparked a police inquiry, which was later widened to include other deaths at the trust.

Mr Titcombe and his wife, a charity worker, have been fighting for five years to find out why mistakes were made in the care of their son.



After Joshua’s death, Mr Titcombe asked the Care Quality Commission to investigate the hospital.

But his concerns – and those of other patients – were ignored and it was not until 2011 that an inquest into the death was held.



They believe that if the regulator had paid proper attention to their concerns, it may have been able to prevent further baby deaths.



Scene: Joshua bled to death at Furness General Hospital (pictured) in Cumbria when he was nine days old

Mr Titcombe said yesterday that Joshua’s sisters Emily, who is eight, and Jessica, who is three, still talk about their lost brother all the time.

He said: ‘We have pictures of Joshua in the house. He’s still part of the family. There’s not a day that goes by when I don’t think about him and have a cry and miss him.



‘It’s the fact that this can happen and there’s so little learning from it that’s the insult. That his life didn’t mean enough for people to properly learn lessons from it.’



'What we wanted is for lessons to be learned by Joshua’s death. But the same systematic problems that led to Joshua’s death went on and on. It was a missed opportunity and babies died as a result' James Titcombe

Mr Titcombe’s campaign, Morecambe Bay Inquiry Action, has 17 active members – some from families who have lost loved ones.



They have worked tirelessly to demand investigations into serious systemic failures by staff sat University Hospitals of Morecambe Bay Foundation Trust.



In March, bereaved mother Liza Brady, 27, revealed how her son Alex died after being born at the hospital with the umbilical cord wrapped around his neck in 2008.



At his inquest, the coroner said the hospital staff had not been working together properly after hearing how midwives ‘shooed’ doctors away during the birth.



And Kelly Hine, 22, told how in 2011, her newborn baby Amelia died in Furness General Hospital after inhaling meconium, the waste product newborn babies produce.



Legal action is now believed to have been taken against the hospital by around 30 families.

The bosses who dodged the flak







Cynthia Bower



Resigned in September: Cynthia Bower was said to have presided over a culture of bullying by bosses obsessed with protecting the CQC's reputation

Former chief executive of the Care Quality Commission, resigned in September with a £1.35million pension pot.



During her four and a half years in charge of the watchdog, she was said to have presided over a culture of bullying by bosses obsessed with protecting the CQC’s reputation.



Astoundingly, Miss Bower, 57, was promoted to the post in 2008 having just missed one of the worst-ever hospital scandals at Mid-Staffordshire.



Between 2006 and 2008 she had been in charge of the West Midlands health authority, which should have been monitoring the hospital while hundreds were dying of poor care.



In fact she has been accused of trying to cover up the high death rates at Mid-Staffs by ordering academics at Birmingham to carry out a separate study, which attempted to discredit official figures.



She eventually left the CQC in February last year after a damning inquiry concluded it was failing to inspect hospitals, care homes and GP practices properly.



The watchdog, which had spent millions on plush refurbishments, staff junkets, Raymond Blanc meals and Krispy Kreme doughnuts, had carried out fewer than half its target number of inspections – a ‘story of failure’ that MPs said ‘went right to the top.’







Dame Jo Williams



Left quietly: Dame Jo Williams was paid £60,000 a year to show up for two days each month - so in effect she earned £2,500 a day

Former chair of the CQC, resigned suddenly last September after she was accused of trying to discredit a whistleblower by saying she was mentally ill.



She was paid £60,000 a year to show up for two days each month – so in effect she earned £2,500 a day.



She left quietly last year after she was accused of trying to sack a whistleblower who raised concerns about the organisation’s failings.



Kay Sheldon, another CQC board member, had tried to warn that patients were being put in danger by the organisation’s poor performance.



But Dame Jo, 64, wrote to the then health secretary Andrew Lansley urging him ‘immediately’ to suspend Miss Sheldon.



Dame Jo allegedly used taxpayers’ money to commission an external mental health assessment of Miss Sheldon – then told the rest of the board that she planned to share its findings with Mr Lansley.



Miss Sheldon later said: ‘They were trying to discredit me as mad. It’s shocking the lengths they were willing to go to.’ Dame Jo was not available for comment. When asked about the Morecambe Bay Hospital report, her husband Rob said: ‘I doubt she will speak about it. As you are aware she has retired from the CQC and she is enjoying her retirement.’



Dame Jo lives in a detached £400,000 Grade II listed Georgian house in the historic city of Chester.







Tony Halsall



Former chief executive: Tony Halsall left last year in disgrace amid a probe into the deaths of 16 babies

The trust’s former chief executive, left last year in disgrace amid a probe into the deaths of 16 babies – but he was still given a severance package worth almost £250,000.



The former nurse, 66, was in charge of University Hospitals of Morecambe Bay at the height of the scandal between 2007 and 2012.



He resigned in disgrace last February but struck a deal with the trust that will see him continue to receive his £150,000 salary until October this year.



He is also entitled to his £5,000 benefits which include a lease car and career management advice.



The combined cost of his salary and the benefits amounts to £225,000 – a figure described as ‘shocking’ by the local lib Dem MP Tim Farron.



After leaving the trust in April, Mr Halsall was appointed an associate director at the NHS Confederation, although his salary is not known.



He has also set up his own private consultancy firm with his wife Jane, offering management advice to hospitals and NHS trusts for a fee.



Mr Halsall, who has enjoyed several luxury holidays since leaving the trust, declined to comment yesterday, saying: ‘I’ve been away for 15 months, I’ve nothing to say.’

Over the last six months other senior CQC directors have quietly left with substantial redundancy packages.

They include Amanda Sherlock, director of operations, Louise Guss, the director of legal services, Allison Beal, the director of human resources, and Jill Finney, the director of communications.

All were on salaries of between £110,000 and £145,000 and joined the organisation in 2009 and 2010. They will have received one month’s pay for every year’s service, amounting to packages worth around £30,000 each.