CQC response to story in The Independent

Published: 3 September 2015 Page last updated: 12 May 2022

A story has been published in The Independent today (Thursday 3 September) focussing on CQC’s response to Regulation 28 reports, which are issued by the Coroner and aimed at preventing future deaths.

The story focusses on a number cases (between 2013 and 2015) where someone died - either in a care home or following care or treatment at home - where the Coroner concluded that further action needed to be taken to prevent a future death in similar circumstances from occurring.

Our Chief Executive, David Behan, gave an interview to The Independent to explain how CQC has improved the processes we have to in place to ensure that we respond to and learn from the issues highlighted by these Regulation 28 reports.  

CQC’s Chief Executive, David Behan, said:.

“When someone dies while being cared for in a health or social care setting and the Coroner concludes that action is needed to prevent future deaths from occurring, a Regulation 28 report is issued. In most cases, the provider will be the named respondent, meaning that they have responsibility for preventing a future death in similar circumstances.

“In some cases, however, CQC is the named respondent, meaning that the Coroner has concluded that the regulator also has a role to play in ensuring that people are protected in the future.

“In those cases where CQC is identified as the named respondent, it is absolutely right that we should expect CQC to use this information to inform our regulatory activities. This includes how we respond to levels of risk as well as ensuring providers act on the recommendations of Coroner’s Reports.

“Last year, I initiated a review of our processes and procedures, as I had recognised that we were not always receiving these Reports. In some cases where we did, it was also clear we were not always dealing with these effectively enough.

“We have made a number of changes to strengthen and tighten our ways of working, including:

  • Establishing a single point of contact for Coroners’ reports to ensure any concerns raised are effectively logged, analysed, managed and reviewed.
  • Better and earlier engagement with Coroners around the time of a person’s death.
  • A proposed and drafted Memorandum of Understanding with the Coroners’ Society to strengthen our working relationships and ensure we receive all Coroners’ reports in health and social care inquests in order to help reduce risk more effectively and promptly.

“We’ve made progress, but I’m far from being complacent. We know there is more work to do. Improvement is a continual commitment and we are making sure we are properly embedding our new process, further developing our relationship with the Coroners’ Society and being really clear about what we expect our staff to do when they receive these types of reports.

“But this isn’t just about processes – it’s about people’s lives.  For that reason, we need to keep working hard to ensure that we get it right every time.”

Improvement is a continual commitment and we are making sure we are properly embedding our new process.

David Behan, Chief Executive