Recommendation 122

Large scale failure of clinical services

Accepted in principle
Large-scale failures of clinical service are likely to have in common a need for:

  • Provision of prompt advice, counselling and support to very distressed and anxious members of the public
  • Swift identification of persons of independence, authority and expertise to lead investigations and reviews
  • A procedure for the recruitment of clinical and other experts to review cases
  • A communications strategy to inform and reassure the public of the processes being adopted
  • Clear lines of responsibility and accountability for the setting up and oversight of such reviews

Such events are of sufficient rarity and importance, and requiring of coordination of the activities of multiple organisations, that the primary responsibility should reside in the National Quality Board

We agree that in the rare circumstances that significant failures are identified as part of regulatory action, part of the response to that failure will be the consideration of advice and information to the public about the nature of that failure and potential support to those directly affected by the issues identified. However, while we also agree that such a response needs clear coordination across a number of involved organisations we do not agree that this should be a function of the National Quality Board.  Rather such action should be part of a response to the single failure regime outlined in recommendation 19 and be agreed jointly between the trust, Care Quality Commission, Monitor and the NHS Trust Development Authority as appropriate to ensure that all those directly involved in the identified failure are work together through that regime.

The Care Quality Commission, Monitor and the NHS Trust Development Authority will work together to publish further guidance, as soon as possible after April 2014, to provide further detail on how these organisations work together to address risks to quality. This will include details of how concerns, including immediate concerns, will be addressed, how and when the single failure regime could be triggered and what guidance and support would be made available to the public in the event of large scale, significant, failure. This guidance will build on the joint policy statement, the Regulation and oversight of NHS Trusts and Foundation Trusts published by the Care Quality Commission, Monitor, NHS Trust Development Authority, NHS England and the Department of Health and the experience from Professor Sir Bruce Keogh’s review into the quality of care and treatment provided by 14 hospital trusts in England which included, for example, an independent review that included the views of clinical and other experts.


No longer is inadequate care left unaddressed.  Where the Care Quality Commission identifies poor care and weak leadership it recommends that an NHS or Foundation Trust is placed in special measures. Monitor and the NHS Trust Development Authority will then decide whether to do so, and may also put Trusts in special measures based on its own evidence without waiting for the Chief Inspector’s recommendation. Monitor and the NHS Trust Development Authority will typically undertake a number of interventions to improve performance and require the Trust to publish progress against an action plan every month.

The Trust will then be re-inspected by the Care Quality Commission after twelve months to assess progress. Following Professor Sir Bruce Keogh’s review into hospitals with high mortality rates, eleven hospitals were put into special measures, and have been provided with extra support from Monitor and the NHS Trust Development Authority.

A further eight Trusts have been placed in special measures after a Care Quality Commission inspection identified that the levels of care were not of an adequate standard. The Care Quality Commission is also introducing a special measures process for primary care and adult social care providers that are rated “inadequate”, to ensure they improve within no more than twelve months, or face losing their registration. In cases of serious breaches of the new fundamental standards, or of risk to people using services, the Care Quality Commission can also use its enforcement powers right away, including prosecution.