England’s health ombudsman has criticised the service’s care regulator for failing to properly investigate the death of a five-year-old boy in a specialist unit.
The boy’s foster mother – an NHS doctor – has accused the care provider that looked after him of instigating “a cover-up” of how he died and frustrating her efforts to get to the truth.
The ombudsman has criticised the Care Quality Commission (CQC) for failing to act on evidence that emerged at the inquest into the boy’s death that cast doubt on the trust’s version of events.
The ruling by Rebecca Hilsenrath, the ombudsman, is another blow to the credibility of the CQC, which the health secretary, Wes Streeting, in July declared to be “not fit for purpose”.
The case shows that the various regulators that monitor the health sector need to ensure that when mistakes are made the care provider displays transparency and accountability, Hilsenrath said.
The ombudsman did not name the boy. He had neurodisabilities and lived in Sheffield with his foster parents, who had looked after him since he was six months old. He was found dead in his cot one morning in May 2017, six weeks into a stay at a specialist residential children’s home in Tadworth, Surrey, run by the Children’s Trust, a charity.
He had been doing well and had no major underlying physical or medical concerns. At first, the CQC believed his death had been natural, based on what the charity had told it.
But the inquest into his death found it had occurred after a loose padded bumper around his cot, to stop injuries or falls, had become dislodged and wedged under his neck. It found that he had died “following entrapment by a loose cot bumper causing death by way of airway obstruction”.
The boy’s foster mother, who asked to remain anonymous, complained to the CQC and, dissatisfied with its response, raised her concerns with the ombudsman.
“When things go wrong in care there should be accountability and lessons must be learned. If that doesn’t happen, grieving families suffer the added pain of having to fight harder to get the answers they’re looking for,” Hilsenrath said.
“Regulatory organisations must make sure they examine all the available evidence to uncover the truth for everyone involved and to prevent others from experiencing the same trauma.”
Dr Karen Henderson, the coroner who heard the inquest, was so concerned by the evidence presented about the Children’s Trust’s behaviour that she issued a prevention of future deaths report – a legal warning that dangers of the same events occurring must be eradicated to protect patients.
In the report, she highlighted that police and coronial staff who attended the trust soon after the boy died “were not fully informed of the circumstances of his death”. For example, they were not told what position his body was found in, that he had been dead “for some time” or that the bumper had been found across his neck.
The trust “have not acknowledged there was a lack of transparency and openness into how [the boy] died or that the trust did not properly investigate his death or inform the relevant statutory bodies of the circumstances of his death”, the coroner added.
After the inquest, the Children’s Trust said it accepted the coroner’s findings and apologised to the boy’s family. In a statement at the time, it said: “Our senior leadership team has established an action group dedicated to developing new processes and systems that will address the coroner’s concerns.
“This is in addition to measures we had already put in place in the last five years since [the boy’s] death; including new beds and cots, and changes to our overnight monitoring policy.”
Speaking to the Guardian, the boy’s foster mother said: “I think there’s no doubt that there’s been a cover-up [by the trust]. I feel really angry. I feel like [her son’s] life didn’t matter.
“The CQC should have been much more curious. As a doctor, I’m used to dealing with the CQC. But I have lost trust in an organisation that should be doing its utmost to make sure that places that look after vulnerable people are safe. They didn’t see that things weren’t adding up here.
“It felt like the CQC were there to protect the trust and its reputation. It’s only the ombudsman that’s got me answers, because they wouldn’t give me any answers.”
James Bullion, the CQC’s chief inspector of adult social care and integrated care, acknowledged that the regulator had let the boy’s family down.
“Everyone has the right to expect safe, high-quality care and a regulator that they can trust to act in their and their loved one’s interest. We fell short in this case and we are deeply sorry for the impact this has had on this young boy’s family.”
• The headline and main text of this article were amended on 3 January 2025 to refer to Rebecca Hilsenrath as “England’s health ombudsman”, not “the NHS ombudsman” as an earlier version said.
