Avis Addison

HSCA Further Information 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Telephone: 
Fax: 03000 616171 

HM Coroner Mr. Andrew Cox 

12 February 2021 

Care Quality Commission (CQC) 
Our Reference: 

Dear HM Senior Coroner 

Prevention  of  future  deaths  report  following  the  Inquest  into  the  death  of 
Avis Mary Addison 

Thank you for your Regulation 28 report to prevent future deaths issued following 
the inquest into the sad death of Avis Mary Addison.  

The role of the Care Quality Commission (CQC) as an independent regulator is to 
register health and adult social care service providers in England and to inspect 
whether  or  not  the  fundamental  standards  are  being  met.  The  legislation  that 
governs this function is The Health and Social Care Act 2008 (Regulated Activities) 
Regulations 2014. 

In  the  regulation  28  report,  you  have  asked  CQC  to  consider  the  following 
concerns: 

Given CQC is the agency responsible for inspection of GP practices, one way 
to ensure GP practices have domestic violence and safeguarding policies in 
place, and to ensure that all staff have received training on their contents, is 
to include checks in this regard as part of your inspection regime. It is,  of 
course, entirely possible that this is already part of the process. 

CQC do not always routinely check all training records as part of an inspection. 
This will depend on the service; the type of inspection and what concerns have 
been raised. 

All providers must comply with the regulations as set out in The Health and Social 
Care  Act  (HSCA)  2008  (Regulated  Activities)  Regulations  2014.  Regulation  12 
(Safe care and treatment) requires providers to assess the risks to people's health 
and  safety  during  any  care  or  treatment  and  make  sure  that  staff  have  the 
qualifications, competence, skills and experience to keep people safe. This would 

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 include how to recognise when vulnerable patients failed to attend appointments 
or collect prescriptions. Regulation 13 (Safeguarding service users from abuse and 
improper  treatment)  includes  ensuring  systems  (policies)  and  processes  were 
established  and  operated  effectively  to  investigate,  immediately upon  becoming 
aware of, any allegation or evidence of abuse. 

A provider’s compliance with the regulations will be assessed at inspection. As part 
of a CQC comprehensive inspection the practice will be inspected against five key 
questions,  whether  a  service  is  safe,  effective,  caring,  responsive  and  well  led. 
Each of the five key questions are broken down into a further set of questions, the 
key lines of enquiry (KLOEs). When CQC inspects, these are used to help CQC 
decide what the inspection needs to focus on. For example, the inspection team 
might  look  at  how  risks  are  identified  and  managed  to  help  them  understand 
whether a service is safe. As part of the consideration as to whether a service is 
safe, CQC will consider how systems, processes and practices keep people safe 
and safeguarded from abuse, how these are monitored and improved and whether 
staff receive effective training in safety systems, processes and practices.  

CQC does not provide a list of mandatory training expected members of the GP 
practice team. This is because training requirements will depend on the role and 
specific responsibilities of practices, and the needs of the people using the service. 
Ultimately,  the  practice  is  responsible  for  determining  what  mandatory  and 
additional  training  staff  need and  how  this  is  delivered.  Although  there  is  no 
definitive list of mandatory training. Examples of training CQC would expect to see 
evidence  of  include  training  to  the  appropriate  level  on safeguarding  adults  at 
risk and safeguarding children. 

(ii)    Another  matter  that  you  may  feel  would  be  beneficial  to  inspect  is 
whether practices have in place some form of ‘early warning system’ where, 
for example, prescriptions are not collected or appointments are cancelled 
without good reason (e.g. by a controlling partner.) 

CQC will consider as part of the inspection of a practice, the systems in place to 
support  the  management  of  vulnerable  patients.  This  includes  a  review  of  the 
process  to  manage  where  patient  prescriptions  have  not  been  collected  or 
appointments are not attended.  

In 2018, an additional prompt was added to the KLOEs, namely “is there a system 
to highlight vulnerable patients on records e.g. children living in care or in houses 
with  domestic  violence,  young  carers, substance misuse,  siblings  of  children on 
child protection plans, people who have experienced domestic abuse, adults and 
children with high numbers of A&E and/or urgent care attendances, female genital 
mutilation (FGM) victims, refugees, patients diagnosed with mental health, patients 
with  severe  mental illness  (SMI)  or patients with  mobility  issues?  Is  there  a  risk 
register of specific patients e.g. SMI Register?” The prompt is to check as part of 
the inspection, that there is a system in place to ensure vulnerable patients are 

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 safe  and  checks  are  undertaken,  that  a  provider  has  flags  on  the  system  to 
highlight a vulnerable patient and if something untoward occurs they are identified, 
and timely action is considered. 

The  Royal  College  of  Nursing  published  their  Intercollegiate  guidance  on  Adult 
Safeguarding: Roles and Competencies for Health Care Staff in August 2018. This 
set  out  the  competencies,  knowledge  and  skills  expected  to  support  adult 
safeguarding, including domestic abuse. This includes ensuring staff are familiar 
with the relevant associated legislation and guidance, including; domestic abuse 
and domestic homicide. CQC responded to this updated guidance by publishing 
further 
inspectors  and  providers  on  safeguarding  roles, 
competencies and functions relating to safeguarding.  

information 

for 

We are currently now in a period of consultation about our next steps of regulation. 
During this time, we will continually keep our scope of regulation under review and 
update our regulatory approaches frequently. This will include strengthening how 
we regulate safeguarding in the future.  

We continue to respond to risk during this consultation period, including concerns 
and issues raised in this report. 

CQC Regulatory Action: 

CQC  undertook  an  inspection  in  March  2019  at  the  GP  practice  where  Avis 
Addison  was  registered  as  a  patient.  This  inspection  was  undertaken  after  the 
death of Mrs Addison. There were no areas of concern in relation to the relevant 
practice  policies,  staff  understanding,  training  and  systems  to  support  the 
management of vulnerable patients in the practice 

Following receipt of the regulation 28 notice, CQC made contact with the registered 
person of the GP practice where Mrs Addison was registered. This was to request 
information in relation to the changes made by the practice in process and policy 
following  the  inquest  and  any  subsequent  updates  and  training  received  by  the 
GP. From the information CQC received from the provider, we were satisfied and 
assured  about  the  management  of  safeguarding  and  vulnerable  patients  in  the 
practice, which demonstrates how they are ensuring people are safe and risks are 
mitigated. 

Where CQC identifies that regulations are not being met, we use our enforcement 
powers to require improvements to be made. We continue to do this and will share 
key learning and practice points from the inquest into the death of  Avis Addison 
with inspectors. 

We hope that this response addresses your concerns. If this is not the case, please 
could you clarify any further details you require.  

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 Yours sincerely 

Head of Inspection- PMS South East and South West. 

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