How is mistake defined

Daniel McMorrow made this Freedom of Information request to Care Quality Commission

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Mr Daniel McMorrow
Flat 64
Rosing Apartments
45 Homesdale Road
Bromley
Kent
BR2 9FN

Dear Care Quality Commission / FIO Officer

I’ve asked on twitter and been ignored so under Freedom Of Information, Under the Act you have 20 working days to respond to this request. You can respond in writing to above address or via email [email address]

I ask…
“How do you define mistake without an investigation ?”

Your ‘new’ power http://www.cqc.org.uk/content/new-regula... use the term “mistake”
Simply put a provide has no formal method of defining a mistake. So they cant be required to open about it.

In my case a Dr wrote to my employer without my consent. I maintain this was revenge for complaints made while under their care.
You did not investigate therefor can’t remain impartial and say otherwise. Would this be classed as a mistake?

To be clear I’m not asking about serious untoward incident (SUI) But the definition of “mistake” without investigation.

Yours faithfully,
Daniel McMorrow

Information Access, Care Quality Commission

 

Dear Mr McMorrow

 

I’m sorry that you did not receive the information you were seeking on
Twitter.

 

You asked for the following information:

 

“How do you define mistake without an investigation ?”

 

Your ‘new’ power
[1]http://www.cqc.org.uk/content/new-regula...
use the term “mistake”

Simply put a provider has no formal method of defining a mistake. So they
cant be required to open about it.

 

 

You are correct that we used the word ‘mistake’ in our website article
explaining the new ‘duty of candour’ requirements that came into force on
1^st April.

 

We said:

 

There are also new requirements for providers on being open about mistakes
when they happen (called the '[2]duty of candour')

 

The word ‘mistakes’ was used in its general sense to convey to the public
the basic purpose of the legal requirement. The word is not contained
within the actual regulation against which we assess and enforce
compliance, therefore there is no need for it to be formally defined in
order for the regulation to be enforced.

 

The link provided in the article takes you to a page -
[3]http://www.cqc.org.uk/content/regulation... - of further
information about the duty of candour, including further guidance and the
full text of the relevant regulations.

 

Regulation 20 of the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2014 requires providers to notify the ‘relevant
person’ (the person receiving care or their appropriate representative)
and to explain and apologise for any ‘notifiable safety incident’. This is
the legal requirement that CQC will monitor and enforce.

 

Regulations 20(8) and 20(9) explain what a ‘notifiable safety incident’ is

 

20(8)   In relation to a health service body, "notifiable safety incident"
means any unintended or unexpected incident that occurred in respect of a
service user during the provision of a regulated activity that, in the
reasonable opinion of a health care professional, could result in, or
appears to have resulted in—

 a. the death of the service user, where the death relates directly to
the incident rather than to the natural course of the service user's
illness or underlying condition, or
 b. severe harm, moderate harm or prolonged psychological harm to the
service user.

20(9).  In relation to a registered person who is not a health service
body, "notifiable safety incident" means any unintended or unexpected
incident that occurred in respect of a service user during the provision
of a regulated activity that, in the reasonable opinion of a health care
professional—

a.    appears to have resulted in—

                                          i.    the death of the service
user, where the death relates directly to the incident rather than to the
natural course of the service user's illness or underlying condition,

                                        ii.    an impairment of the
sensory, motor or intellectual functions of the service user which has
lasted, or is likely to last, for a continuous period of at least 28 days,

                                       iii.    changes to the structure of
the service user's body,

                                       iv.    the service user
experiencing prolonged pain or prolonged psychological harm, or

                                        v.    the shortening of the life
expectancy of the service user; or

 

b.    requires treatment by a health care professional in order to
prevent—

i. the death of the service user, or
ii. any injury to the service user which, if left untreated, would lead
to one or more of the outcomes mentioned in sub-paragraph (a).

 

I hope that this has been useful to you.

 

If you wish to make any further requests for recorded information held by
CQC, please contact us at [4][CQC request email]. 

 

Feedback

 

CQC will always endeavour to provide the highest quality responses to
requests for information and seek to provide responses that are as helpful
as possible. We would therefore appreciate if you can complete our online
feedback form by visiting the following website:

 

[5]http://webdataforms.cqc.org.uk/Checkbox/...

 

Any information you provide will be held securely and only used for the
purposes of improving the Information Rights service that CQC provide.

 

If you have any queries please do not hesitate to contact the team at
[6][email address].

 

Yours sincerely

 

Simon

 

 

Simon Richardson

Information Access Team

Care Quality Commission

 

 

The Care Quality Commission is the independent regulator of all health and
adult social care in England. [7]www.cqc.org.uk. For general enquiries,
telephone the National Contact Centre: 03000 616161.

Statutory requests for information made pursuant to access to information
legislation, such as the Data Protection Act 1998 and the Freedom of
Information Act 2000, should be sent to: [8][CQC request email]

 

 

 

show quoted sections

References

Visible links
1. http://www.cqc.org.uk/content/new-regula...
2. http://www.cqc.org.uk/content/regulation...
3. http://www.cqc.org.uk/content/regulation...
4. mailto:[CQC request email]
5. http://webdataforms.cqc.org.uk/Checkbox/...
6. mailto:[email address]
7. http://www.cqc.org.uk/
8. mailto:[CQC request email]

Boris Campbell left an annotation ()

But 'mistakes' must be proven.

Steven King left an annotation ()

Maybe for clarity you should ask not only how they define a ' mistake ' but also a ' deliberate ' harmful action, ( which it could be seen to be here ? ) breach of NHS regulations or guidelines, and a breach of UK Legislation ?

You have the opportunity to request a review and ask for clarification of these and other points - maybe by also enquiring about how the word ' care ' is defined , as possibly not only the person receiving care ( and does that apply not only to the treatment , and maybe level of service ? ) but also the carer / partner / person who is looking after someone who is ill and asks for support or advice , is also entitled to receive a totally clear and acceptable level of service from the NHS provider - and surely if they dont they too should be covered under this candour Legislation and the NHS and CQC guidance and definitions ?

Boris Campbell left an annotation ()

Perhaps you should have a look at paras 46- 50 of the 2008 Health and Social Care Act, which deal with reviews and investigations.
Section 48(special reviews and investigations) was amended by para 293 of the 2012 HSCA, where a new section (1A) was added, permitting CQC to conduct an investigation WITHOUT the approval of the Secretary of State, thus removing one bureaucratic layer. Whether for good or not, is yet to be seen.

Fiona Watts left an annotation ()

Daniel,

Thank you for this FOI request and for SPOTLIGHTING the apparent farce that seems to be The PHSO.

Thank you to Boris and Steven for their helpful contributions and to this site for providing an opportunity for us to empower ourselves against the "Franz Kafka-The Castle" - style nightmare of the PHSO.

I quote a section of their earlier response to you in this FOI;

"Regulation 20 of the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2014 requires providers to notify the ‘relevant
person’ (the person receiving care or their appropriate representative)
and to explain and apologise for any ‘notifiable safety incident’. This is
the legal requirement that CQC will monitor and enforce"

.... lol! What a comedy FOI moment!

Hello?

The PHSO respond to you under the premis that the CQC are fit for purpose for the task. The PHSO imply that the CQC are pro-active in monitoring or reviewing the incident?

Unfortunately, the PHSO response to your FOI demonstrates the way that dodgy NHS sites slip under the radar of any fit for purpose scrutiny. The CQC refers to the work of the PHSO and visa versa - but both organisations do not have strict enough protocols and systems to ensure Public Safety.

As demonstrated here, the CQC only act on that data provided to them by the NHS Trust or department that they are supposed to be "investigating". The way these NHS sites are able to so easily hoodwink the CQC makes an utter farce of the their whole remit!

For example, I refer the PHSO to this FOI request made by me in February this year.
https://www.whatdotheyknow.com/request/c...

There were three NHS Foundation sites in Bury St Edmunds, but The Norfolk and Suffolk NHS Foundation Trust were only told about ONE site. So ... the CQC only reviewed the operations at ONE site and ignored the other two. In fact they didnt even know about the other two sites!

But nevermind... the CQC references the PHSO and visa versa - whilst those of us trying to work out how two companies can seem SO inept - get bounced between them both.

Kapeesh Steven?!!

Boris Campbell left an annotation ()

Indeed, that's how it is. I should ask you to have a look at my latest request to the LGO regarding 'Social Care Ombudsman' and submissions by others to the LGO.
You will see that I asked the LGO about SCO, to which they replied, after a fashion.
What is interesting is that the LGO claims to be the 'Social Care Ombudsman', when in fact the LGA 1974 does not even mention the word 'care' once in the context of 'social care'. The name is rather confusing and it may be claimed to be misleading the public.
The Health and Social Care Act 2008 in para 50 gives the CQC powers to review/investigate social care provided by local authorities. To me it seems to be a clear 'duplication' of effort. In the LGO's case assumed one, whereas on the CQC's an explicit one. The CQC does not differentiate between 'adult' and 'child' social care, whereas the LGO deals only with 'adult' social care. Who then, deals with 'child care'?
What is also baffling is that the LGO was given 'powers' by the HSCA 2012 edition, to deal with 'privately arranged or funded social care'. I fail to see how and why a local authority, let alone the LGO should get involved in care arranged privately and paid for from private funds. I am sure that any local authority will tell anyone who presents a complaint about a 'private' care to get lost, as it is none of local authority's business to get involved in private matters....
The CQC told me that it was NOT responsible for reviews/investigations into adult social care and referred me to the LGO. I have asked the CQC for its understanding of para 50,I have been asked twice by CQC for an extension to reply, It is now again outstanding.
See my response to the LGO regarding SCI in the next couple of days.

Steven King left an annotation ()

Fiona Watts 17 May
Have read your annotation carefully.

An example of systemic failure at CQC follows :

I was, and still am , suffering abuse from my NHS Mental Health Trust staff , that is all well documented and audio recorded to prove.

The CQC were about to carry out a major inspection of this trust, with some 50 - 60 inspectors , so as requested by CQC I contacted them and was put through to their safeguarding team - a selection made by number following CQC answering my call automatically.

I spoke with an extremely helpful and apparently sincere lady, who I asked to type up everything I wished to report - and she did so without any problem - on this occasion.

I reported a number of VERY serious matters - including the abuse of other vulnerable adults I had heard openly discussed at a public meeeting .

The lady said these were very serious matters, read her typed version back to me twice , and I confirmed I was content she had recorded it accurately.

She TWICE gave me the same reference number - and asked me to read it back to her which I did.

She told me this report would go into their safeguarding system to be acted upon, and that the lead inspector for the NHS Trust would also be sent a full copy of my report.

Sure enough, that evening the lead inspector telephoned me from her home on a mobile - maybe her choice of time to communicate with me as no recording of her call was made - hence the content of her discussion with me cannot be seen or proved.

I felt she was on the defensive and building barriers throughout .

The CQC reported MY safeguarding alert to my local council - who buried it and did nothing - along with many others they have received regarding myself from professionals I have had no previous contact with !

I made an SAR under DPA to the CQC - asking for ALL of my qualifying data and received a mass of data - but NOT the Safeguarding alert and report I had made mentioned above - even though I quoted the time, date , person I spoke with and the reference number I was given.

Of interest , although someone at CQC clearly chose to BURY this very serious report I had made, there was a record that the lead inspector had telephone me the same day and had a long discussion - but not mention of the content of the discussion or the report I had made !

I pursued this matter, but had many barriers put up by CQC
who I feel ducked and dived for months - but NEVER produced the report !!

Can I trust the CQC to carry out their own duties and responsibilities under Legislation and their own policies etc -
I dont think so !

Daniel McMorrow left an annotation ()

I had the same. A Dr broke my medical privacy and responded to a letter from my former employer. I had ask them not to respond.
I maintain this letter was retribution for complaints made while at this hospital. A later CQC inspection supported my complaints. Most safety related.

It took the CQC a year to tell me they can't investigate. The CQC can't refute my claim of retribution as they did not investigate.