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Care Quality Commission: Morecambe Bay Hospitals

Volume 746: debated on Thursday 20 June 2013


My Lords, with the leave of the House, I shall now repeat a Statement made in another place yesterday by my right honourable friend the Secretary of State for Health on Morecambe Bay Hospitals. The Statement is as follows.

“I wish to make a Statement about today’s independent report into the CQC’s regulatory oversight of University Hospitals, Morecambe Bay. 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 and, in that context, I know that the whole House will wish to extend our condolences to every one of them.

Joshua Titcombe’s tragic death was one of 12 serious untoward incidents, including five in the maternity department. His family and others have had to work tirelessly to expose the truth—and I want to pay tribute to them for that—but the fact is that they should not have had to go to such lengths. As we saw with Mid Staffs, a culture in the NHS had been allowed to develop in which defensiveness and secrecy were put ahead of patient safety and care. Today I want to explain to the House what the Government are doing to root out that culture and ensure that that kind of cover-up never happens again.

The independent report was commissioned by the new chief executive of the CQC, and the new team running the organisation has made it clear that there was a completely unacceptable attempt to cover up the deficiencies at the CQC. The report lists what went wrong. Unclear regulatory processes, reports commissioned and then deleted, lack of sharing of key information and communication problems throughout the organisation. Most of the facts are not in dispute. All of them are unacceptable. They have compounded the grief of the Titcombe family and many others.

The role of the regulator is to be a champion for patients, to expose poor care and to ensure that steps are taken to root it out. It must do this without fear or favour. It is clear that at Morecambe Bay the CQC failed in that fundamental duty. We now have a new leadership at the CQC and we should recognise its role in turning things around. David Behan was appointed chief executive in July 2012. One of his very first acts was to commission the report that we are now debating. David Prior was appointed the new chairman in January this year. He has rightly insisted that this report be published as soon as possible. Those two outstanding individuals have never shrunk from addressing head on the failings of the organisation they inherited and are wholly committed to turning the CQC into the fearless independent regulator the House would like to see. While I do not underestimate the challenge, I have every confidence in their ability to undertake it. David Prior will now report back to me on what further actions the CQC will take in response to the report, including internal disciplinary procedures and any other appropriate sanctions on individuals.

Working with the CQC and following the Francis report into the tragedy at Mid Staffs, the Government are putting in place far-reaching measures to put patient care and patient safety at the heart of how the NHS is regulated. The CQC is appointing three new chief inspectors—of hospitals, social care and general practice. This will provide an authoritative, independent voice on the quality of care in all the providers that the CQC regulates. The commission has already announced the appointment of Professor Sir Mike Richards as the new Chief Inspector of Hospitals and on Monday the CQC launched a consultation, “A New Start”, which outlines its new much tougher regulatory approach. This includes putting in place more specialist inspection teams with clinical expertise. It will include Ofsted-style performance ratings so that every member of the public can know how well their local hospital is doing, just as they do for their local school.

The Government will also amend the CQC registration requirements so that they include an emphasis on fundamental standards—the basic levels below which care must never fall, such as making sure patients are properly fed, washed and treated with dignity and respect. Failure to adhere to these will result in serious consequences for providers, including, potentially, criminal prosecution. The revised registration requirements will also include a new statutory duty of candour on providers that will require them to tell patients and regulators where there are failings in care—a failure that was identified clearly in today’s report.

Finally, we are putting in place, through the Care Bill, a new robust single failure regime for NHS hospitals. This will provide a more effective mechanism to address persistent failings in the quality of care, including the automatic suspension of trust boards when failings are not addressed promptly.

The events at Morecambe Bay, Mid Staffs and many other hospitals should never have been covered up, but they should never have happened in the first place, either. To prevent such tragedies we need to transform the approach to patient safety in our NHS. The Prime Minister has therefore asked Professor Don Berwick, President Obama’s former health adviser and one of the world’s foremost experts on patient safety, to advise us on how to create the right safety culture in the NHS. He and his committee will report later this summer.

In addition, later this year we will start to publish surgeon-level outcomes data for a wide range of surgical specialties. Most of all, we need a culture where, from the top to the bottom of NHS organisations, everyone is focused on reducing the chances of harming a patient in the course of their care, and a culture of openness and transparency to ensure that, when tragedies do occur, they are dealt with honestly so that any lessons can be learnt. Our thousands of dedicated doctors, nurses and healthcare assistants want nothing more than to be allowed to make this happen. We must not let them down or the families who suffered in Morecambe Bay”.

My Lords, that concludes the Statement.

My Lords, I am grateful to the noble Earl for repeating the Statement, and I declare my interest as a consultant trainer with Cumberlege Connections and as chair of the Heart of England NHS Foundation Trust. Yesterday’s report will have left your Lordships shocked. The noble Earl began with an apology and we on this side of the House echo that apology. Of course, it is a sad fact of life that mistakes will be made. What is never acceptable is when people or organisations try to hide those mistakes. Sadly, this is what appears to have happened in this case.

The report covers a four-year period up until autumn 2012 and deals with failures in regulation, but also with subsequent attempts at a cover-up. It was only published thanks to the efforts of James Titcombe and his family, and I echo the tributes that the noble Earl has paid to him. It is essential that he and all the other families affected in Lancashire and Cumbria get the answers they are looking for. We on this side of the House are fully committed to making sure that this happens.

The most shocking revelation in this report is that in March 2012 an instruction was given by a member of senior management at the CQC to delete the findings of an internal review. Today’s report says:

“we did find evidence of the apparently deliberate suppression of an internal CQC report … and the alleged decision to suppress it … may constitute a broader and on-going cover-up”.

When one considers the context in which this takes place, it is truly shocking. At that time, we were almost two years into a public inquiry into the failings at Mid Staffordshire. That followed an earlier independent inquiry, also led by Robert Francis, following which all parts of the NHS had committed to full openness and transparency. It came after failings at other trusts, most notably Basildon and Thurrock, had been made available, which led to the Opposition calling for an in-depth look at hospitals and a new assurance that they were safe. That is why yesterday’s report is so hard to comprehend. It raises serious questions for the CQC and the Government, which I will take in turn.

On the question of the CQC, I agree with the noble Earl’s assessment of the quality of the new leadership team at the CQC. I commend the new chief executive, David Behan, for commissioning this report. However, yesterday the chair, Mr David Prior, said that he wants to draw a line under the issue. Does the noble Earl agree with me that that line can be drawn only when further questions about the report are answered?

On the cover-up, paragraph 1.17 of the summary of the report says, as I said earlier, that the order to delete,

“may constitute a broader and on-going cover-up”.

Will the noble Earl address this point directly and tell the House whether he is confident that this cover-up is no longer happening? Is he satisfied that the CQC is taking all appropriate steps, and does he have full confidence going forward, or does he believe that a further process of investigation is necessary?

More specifically, is anybody who is involved in the decision to delete that report still working at the CQC or elsewhere in the National Health Service? If they are, I think the public will find that very hard to accept. Given that accountability is essential, does he agree that the public would find it very hard indeed to accept data protection laws standing in the way of this? Will he therefore review the decision to shield the identities of those involved?

The noble Earl will probably have heard the Information Commissioner, speaking today about the use of the Data Protection Act, saying, as I understand it, that there is no blanket ban under the Data Protection Act that would deal with a situation like that, and that if there is an overriding public interest in the names being in the public domain, the Data Protection Act should not be prayed in aid.

I know that the CQC is now seeking further legal advice, and that is welcome. In the end, does the noble Earl agree that sometimes organisations have to override legal advice and do the right thing? I hope the CQC will do that and do it quickly.

Turning to the noble Earl’s department, can I just have it confirmed that the decision to delete the report was taken solely by senior management at the CQC? Can he confirm that officials in his department were not aware of that deleted internal report and were not involved in any discussions between the CQC and the department about it?

Yesterday, at Prime Minister’s Questions, the Prime Minister said that there should always be support for whistleblowers, and he was right. However, there are serious doubts about whether that happened in this case. Concerns about the CQC were raised by a whistleblower, but I understand that she was then subject to attempts to remove her from the CQC board. The noble Earl will recall that I raised this in the House, and he very kindly took action on the matter. It has been reported that the same whistleblower told the CQC board yesterday that she raised issues internally first and then within the department, including directly with the then Secretary of State, in a meeting. Is the noble Earl prepared to release the minutes of those meetings?

We note the important work of Mr Don Berwick, but should we not be getting on with implementing the recommendations of the Francis report in this regard? The Care Bill, which is now in your Lordships’ House, is an ideal vehicle for implementing Francis but is remarkably light on clauses relating to Robert Francis’s recommendations. His report emphasised the need for openness, transparency and candour. Openness will enable concerns and complaints to be raised freely and without having questions to answer. Transparency will enable the truth about performance and outcomes to be shared with everybody with an interest in it. Candour will ensure that any person harmed by the provision of a healthcare service is informed of that fact and an appropriate remedy offered.

Francis made specific recommendations, including that a statutory obligation should be imposed to observe a duty of candour. He wanted healthcare providers who believe or suspect that the treatment or care provided to a patient has caused death or serious injury to inform that patient, or a duly authorised person, of that fact as soon as practical. He said there should be a statutory duty on all directors of healthcare organisations to be truthful and that it should be made a criminal offence for any registered medical practitioner to knowingly obstruct another in the performance of the statutory duties that he wished to see enacted, to provide information to a patient or nearest relative intending to mislead, or to dishonestly make an untruthful statement. However, the only offence in the Bill is a corporate one of providing “false or misleading information”. That is not a duty of candour, so I was very surprised to see the Secretary of State say yesterday in the other place that there would be a duty of candour in the Care Bill. It is not in the Care Bill and I do not think that secondary legislation is sufficient.

Does the noble Earl also not agree, in the light of what happened at the CQC, that it is perverse that the duty not to provide false or misleading information applies only to providers? It does not apply to the CQC; to the other regulator, Monitor; to NHS England; or to his own department. Is he prepared to agree to amendments to the Care Bill on Report to extend this duty to the organisation that has been found so grievously to suppress information that it found itself uncomfortable with?

There is clearly a real problem about the approach that the CQC has taken to hospital regulation. Is the noble Earl willing to have a lengthier debate about regulation? I wonder whether we are just putting too much responsibility on regulators and not enough on the people who actually provide those services. I particularly worry about what he says about the introduction of Ofsted-style ratings into the health service. He will have seen evidence from a number of medical bodies, which are concerned that this is going to be too simple a process when judging something as complex as a hospital.

A hospital may be given a 1 rating—an outstanding rating Ofsted-style—but inevitably within a large hospital, although overall it may be a category 1 there are likely to be services that are not so good. My worry is that a hospital, because it has been given a 1, will not then be reinspected for a number of years, which is the Ofsted style, and its weaknesses will go undetected. When at some point a real problem with patient care comes into the open, it will undermine the whole credibility of the exercise undertaken by the CQC.

We know that the CQC has really been pushed into this by the Government and the Prime Minister. I hope it will be given the flexibility to come up with a more sophisticated approach. We do not want to set the CQC up for failures in the future. I am very fearful that a simple grading of 1 to 4 is almost guaranteed to do that. Overall, I am glad the Government have brought this Statement to Parliament. It is very important indeed that the messages and lessons are learnt. However, we need a much wider debate about the role of regulation in the health service and about whether the practicalities of this can be taken forward effectively by the CQC.

My Lords, I am grateful to the noble Lord, Lord Hunt, for his measured comments, and I am the first to agree with him that the report we now have is very deeply worrying. It sets out conclusions about the CQC’s leadership and operation during the period in question that are very shocking. What happened was totally unacceptable.

The CQC today is a different organisation and I was glad to hear that the noble Lord recognised that. Its board and management team have been completely overhauled. A new chief executive and chair are in post. A powerful new Chief Inspector of Hospitals has been appointed, an appointment that has been welcomed widely. The new leadership, as the Statement said, commissioned and published this report to make sure that the events of the past are exposed and that lessons can be learnt from them.

I am very pleased that the CQC will now be overseeing the production of a report within the next two months to provide assurance that any cover-up has been fully exposed and stopped and that the mistakes made by the CQC in regard to Morecambe Bay hospitals are being put right. That will ensure that the organisation’s structures and procedures are such that these shocking events cannot be repeated.

The noble Lord referred to what I agree with him is the troubling issue of the anonymisation of names in this report. Our clear understanding from the CQC was that its legal advice was that the report had to be anonymised prior to publication to comply with data protection legislation. We asked the CQC to consider this further and to provide advice on whether it was possible to release the names. Yesterday, it gave a commitment to do just that. It has now done so and my understanding is that it will later today publish the names of certain individuals currently anonymised in the Grant Thornton report.

The noble Lord asked whether the Department of Health had seen the report prepared by the CQC, which was then withheld. We have extensively asked officials throughout the department. There is no evidence to suggest that anyone in the department knew that the CQC had commissioned a report into its handling of Morecambe Bay and subsequently withheld it, still less that anyone actually saw it.

The noble Lord raised the issue of the whistleblower, Kay Sheldon. Her concerns about the CQC’s capability were considered alongside a range of other evidence as part of the DoH performance and capability review that was carried out between October 2011 and February 2012. The issues she subsequently raised have been considered along with other information as part of the department’s ongoing oversight of the regulator. The appointment of David Prior as chair of the CQC in January and David Behan as chief executive last July, combined with a strengthened board and the CQC’s new strategy, puts the organisation in a good position for the future.

When Kay Sheldon approached the department she was asked to raise the issues with the CQC board, and DoH officials also raised the issues with the CQC team in line with our normal approach to operational issues. The noble Lord asked whether we will release the minutes of the meeting with Kay Sheldon and the Secretary of State. I am happy to take that request away and I will let the noble Lord know whether that will be possible.

The noble Lord rightly raised the issue of culture in the NHS. The overriding message from the document that we published, Patients First and Foremost, which arose out of Mid Staffs, is that the culture of the NHS governs the quality of everything it does. We are clear that radical transparency, excellence in leadership, clarity of accountability and consequences for failure are together necessary if we are to maintain in the NHS the focus on quality and safety and for concerns to be identified quickly and acted upon.

Transforming culture is a complex challenge that will be different in each organisation. We believe that a combination of the steps that we have set out, such as ratings, which we will debate during the course of the Care Bill, a Chief Inspector of Hospitals and a failure regime that puts quality on a par with financial failure will contribute to making a real difference to the experience of patients. I look forward to the debate on ratings because I know that the noble Lord has concerns about the idea.

The noble Lord referred specifically to the duty of candour. In our response to the Francis report we said that we would introduce a new statutory duty of candour on providers. We agree that it is essential that providers of health and social care must be open in their dealings with patients and service users. We intend to introduce an explicit duty of candour on providers as a CQC registration requirement. That will require providers to ensure that staff and clinicians are open with patients and service users where there are failings in care.

As with all requirements for registration with the CQC, our intention is that the duty of candour will be set in secondary and not primary legislation. I am sure that my right honourable friend the Secretary of State would not mind me saying that he made a slip of the tongue yesterday. He meant to say that a statutory duty of candour will be put in place. However, I emphasise that the duty will have the same legal power in secondary legislation as it would in primary legislation.

The noble Lord made a number of powerful points on false and misleading information. The Care Bill will make it a criminal offence for care providers to give false or misleading information where information is required by a legal obligation. We will specify through regulations the type of information within scope of the offence. However, a failure to provide information would be a breach of the relevant legal requirement to provide it and would be subject to appropriate action.

In determining the scope of the false or misleading information offence, our current focus is on information supplied by providers who are closest to patient care, in which inaccurate statements can allow poor and dangerous care to continue. We need to give further consideration to the events highlighted in the Grant Thornton report and to reflect on whether a false or misleading information offence should apply to other health bodies such as regulators.

My Lords, I welcome the Statement made by the noble Earl, particularly in respect to the CQC’s new focus on being a champion for patients, putting safety and care at the heart of the system and having more specialist teams. I am particularly pleased that David Behan has been appointed as the new chief executive. However, I am extremely concerned that another scandal is looming round the corner. There are very strong warnings. I am extremely concerned that mental health patients detained under the Mental Health Act are very poorly served at the moment. To put this in context, the CQC was formed from three organisations: the Healthcare Commission, the Commission for Social Care Inspection, and the Mental Health Act Commission. The Mental Health Act Commission was not an inspectorate—it was a visitorial body, and looked after the care and treatment of detained patients. It did so by employing a number of commissioners with specialist expertise, not only in understanding the issues faced by mental health patients but also in mental health law, which is so important.

I am coming to the question.

As the former chairman of the Mental Health Act Commission, I was assured when those organisations merged that the CQC would keep the focus of those commissioners, those skills and that methodology, and that specialist focus and attention would be given. That is legally required under the Mental Health Act, but it has not happened. Over the last few years the expertise of Mental Health Act commissioners has been eroded. Can the Minister assure me that this focus will be renewed, and the focus of Mental Health Act commissioners returned? Will the Government consider having a chief inspector of mental health? That was one of the original ideas when it was formed.

I remind noble Lords that brief questions are allowed. As the Companion states, this is not the occasion for an immediate debate. I note that many noble Lords want to speak, so the briefer the better, please.

My Lords, I recall the noble Lord, Lord Patel of Bradford, making those points very powerfully some years ago when we debated the Bill that created the CQC. He makes an extremely important point. I think that we can take it from the statements of David Prior yesterday that the decision taken in 2009 to take a generalist approach to inspection was a mistake. The CQC’s inspectors are in one sense specialist inspectors who are trained and supported to carry out their role, which they do to the best of their ability. However, requiring inspectors to have oversight of a wide range of service types from slimming clinics to acute hospitals, and indeed mental health establishments, has spread expertise too thinly.

We are clear that we must now work with the CQC to create a much more specialist approach to inspection, including on mental health. I think that the three new chief inspectors we are appointing will help to do that. It is not the whole answer, because they need to be supported by clinical expertise and by the people who are experts by virtue of their experience in care services. However, I will take away the noble Lord’s idea of a chief inspector of mental health. I must be honest with him that we have not discussed this, but I am sure that we now should.

My Lords, I wonder if my noble friend would take account of the suggestion of the noble Lord, Lord Hunt of Kings Heath, that legal advice can sometimes prevent people from doing the right thing. I was very sorry to hear that. I think that good legal advice should in fact produce the result of people doing the right thing. The second point I want to make relates to the claims against the health service for negligence. These have been quite substantial over the years. Could the CQC look at that area and examine the grass-roots standard of care given to patients?

My Lords, the deputy Information Commissioner is quoted as saying that confidentiality and data protection issues should not stand in the way of disclosure where disclosure is clearly in the public interest. I completely agree with that. That is why our instant reaction yesterday, when we were told by the CQC that legal advice had said that the names of the individuals had to be kept confidential, was to challenge that. I am pleased that that decision is to be reversed and the names will be released.

On my noble and learned friend’s second point, most certainly yes: the CQC should take a view about matters relating to negligence. However, I would add that apart from the CQC, we now have the new Healthwatch bodies, part of whose function will be to make sure they provide good soft intelligence on what is happening in NHS and social providers in their local areas. The Healthwatch bodies can then act as the eyes and ears of the CQC, which, with the best will in the world, cannot be everywhere at once. In terms of the future—this is clearly a longer-term agenda—I hope we will have a system that is better equipped to pick up this kind of incident should it ever occur again.

My Lords, I welcome the idea of a statutory duty of candour and all the other means of regulation being discussed, but what appears to have happened here—and obviously it is just an allegation—is a simple case of malfeasance in public office. One of the things that seem to have happened over scandals such as Stafford, or even LIBOR, is that the ordinary criminal law of the United Kingdom has not been considered. I assume that the CQC is a public body. It is certainly paid for by public funds, and therefore its officials are subject to the common law.

My Lords, clearly it is a matter for the police to investigate criminal offences and for the Crown Prosecution Service to consider whether the test for prosecuting individuals has been met in this case. It is too early to reach a conclusion about whether this case highlights a gap in the law but if it does, I can assure the noble Lord that we will pursue it. We keep the criminal law under review. It is too early for me to say—I am not a lawyer—whether he is right, but I am sure that his comments will resonate strongly with the House.

My Lords, chaplains occupy a unique position in hospitals in relation not just to patients but to staff. Will the Department of Health keep under review the role of the chaplain in relation to both patients and staff, especially when a culture of carelessness and intimidation emerges?

The right reverend Prelate makes an extremely important point. The Government have been very supportive of the concept of hospital chaplains, who play an enormously important role in supporting not just patients but staff. I am concerned because I have heard anecdotally that in some hospitals there are moves to dispense with hospital chaplains. I am in touch with one of his right reverend colleagues about this. Once again, we have a mechanism—if I may call them a mechanism—that could be deployed to good effect in this context.

The Government’s support for the current leadership and the newly launched New Start consultation will be welcome to all those of us who know the current people. Can the Minister assure the House that the Government will stand firm in this support when the tabloid press starts calling, as it surely will, for more heads to roll? Will he further assure the House that he believes that the last thing that the CQC needs is more change at the top?

I agree fully with everything that the noble Baroness has said. We have in the CQC the right team to take it forward. They are very clear that there needs to be a complete refresh of the senior team where doubts emerge about the individuals concerned. We are already seeing a complete refresh of the board. I share her worry about the tabloid press and calls for heads to roll. Nevertheless, it is appropriate, in the particular context of Morecambe Bay, for there to be a close look at the role of certain individuals: exactly what they did, what they knew, when they knew it and whether what they did was either wrong morally or against the law.

My Lords, I wish to refer to the introduction of a new, robust, single-failure regime for NHS hospitals. This will provide a more effective mechanism to address persistent failings in the quality of care, including the automatic suspension of trusts. As a nurse, I was trained to look at prevention rather than cure. Ought we to be looking at, and including in this, the preparation of trust boards, as well as the staff, looking across the consensus of the trust rather than concentrating on targets? It is often mentioned in reports that they do not look at the quality. We need to see a much more cohesive trust report.

My Lords, this is one of the reasons why the previous Government introduced quality accounts, which are becoming more and more sophisticated and which focus the minds of a board on quality of care. It is easy to give the impression that we want to introduce a punitive culture into the NHS: we do not. However, there should be sanctions in the background to back up any serious failings of care. That is broadly what Robert Francis was driving at in talking about fundamental standards below which no care provider should fall. The CQC will be consulting on those standards later in the year, but I take the noble Baroness’s point about trust boards. It remains within the powers and competence of Monitor to suspend trust boards, either in whole or in part, where concerns arise over the governance of an organisation. That is a drastic power to invoke and they can take measures which fall short of it where appropriate.

My Lords, am I alone in being surprised that it should be necessary to have legislative change to secure a duty of candour? Does this mean that, in the absence of this change, the CQC has the right to tell lies?

My other question is on the inspection regime. I understand that a generic system used to work in the past, whereby somebody whose expertise was in dentistry was sent off to inspect an A&E department. Who was responsible for the decision to run the inspection regime in that way?

My Lords, there has never been a right to tell lies, either professionally or in statute. My noble friend is right that we should be shocked that it is necessary to put in legislation that there has to be a statutory duty of candour. Candour has been part and parcel of the ethical framework for professionals in the health and care sector for many years. It is a sad reflection on those involved in the events at Mid Staffs and Morecombe Bay that we should be thinking in these terms at all, but we must, because unless we do we lay ourselves open to matters being brushed under the carpet, as they have been in these cases.

The inspections themselves have not been generic: it is the skills on the part of the inspectors that were considered to be adequate as those individuals were deployed generically. That decision was taken very early on when the CQC first came into being in 2009. We now think, as does the CQC, that that was wrong and that skills should be altogether more specialist.

As someone who lives in the catchment area of Barrow-in-Furness hospital, I have followed the story very closely. Does the Minister agree that, while we are discussing the cover-up by the CQC today, it in turn was investigating shortcomings by what was presumably the previous management of Morecambe Bay hospitals? Did he see the very pointed quote yesterday in the other place by the MP for Barrow-in-Furness, John Woodcock, who has done so much in this? He quoted the report as saying that there could be a “broader and ongoing cover-up”. Can he give the House an assurance that any investigation will not stop at the CQC but will look at the main cause of the disturbance and Mr Titcombe’s complaint initially?

My Lords, I can give that assurance. In part, we have the answers in the Grant Thornton report commissioned by the CQC on the actions that the CQC took or did not take. As I said in answer to the question asked by the noble Lord, Lord Hunt, it is reassuring that the chief executive of the CQC has undertaken to produce for the department within the next two months a report to provide assurance that any cover-up has been fully exposed and that we will learn fully not only the facts but the lessons that we can draw from them.

I thank the noble Earl for repeating the Statement. It has caused quite a stir. My worry is two-fold. First, we had a big reaction to what happened at Mid Staffs, and now we have this. I would want us to be very careful not to become desensitised by some of these things—I do not mean in this House, but elsewhere.

I will pick up on the comments of the noble Baroness, Lady Emerton, and agree with her totally. As chairman of Barnet and Chase Farm Hospitals NHS Trust, I find it bewildering that, never mind any cover-up at the CQC, the board was not aware of those tragic deaths of mothers and babies. Certainly, in my trust that would absolutely be reported, both through the quality and safety committee that deals with what are called SUIs, or serious untoward incidents, and from the board itself. It would be helpful, as has been suggested, that the inquiry goes a bit further than just the CQC.

I am grateful to the noble Baroness. In fact, the trust has taken significant action in response to the concerns raised by the CQC and Monitor. In addition to responding specifically to the three warning notices issued by the CQC, there have been significant leadership changes at the trust. Sir David Henshaw was appointed as interim chair and Eric Morton as interim chief executive. The trust appointed four new non-executive directors and a new chief operating officer and recruited a new obstetric consultant and additional midwives. There have been other appointments as well. It has established a programme management office, as requested by Monitor, to oversee the implementation of programmes of work to bring about lasting improvements across the trust—and it has recruited a number of posts to the programme office to take that work forward. So I am encouraged that it is taking the position as seriously as it should in the circumstances and that, again, there is a refreshed team at the top of that organisation.

Very often, when we have these inquiries, they are initiated not so much by the people who work within the trusts but by members of the public who feel very concerned about the quality of care being given within a hospital or service. Very often, those people who bring up these concerns, who are dubbed colloquially as whistleblowers, get very victimised by other people within the population but also within the hospital. Is there any support or help that we can give those people who bring to the attention of the NHS some of the problems that exist?

My noble friend raises a key issue, which successive Governments have wrestled with. We all know how life works. Whistleblowers are treated badly because their message is often very uncomfortable. That is why local Healthwatch could potentially be a very important part of the puzzle here, by ensuring that people have a place to go to that they can trust and that can raise concerns without necessarily naming the person who has initiated those concerns.

More and more, we need to encourage providers of care to take ownership of their performance. They have to be candid with themselves and accept criticism where it is laid. Boards of directors have to look systematically and regularly at the complaints made against them—whether rightly or wrongly—to make sure that they are as open as possible with themselves. Only by instilling a culture of that kind can we move forward.