Published Fri, 2011-10-07 12:30; updated 34 weeks ago.
Health watchdog the Care Quality Commission (CQC) has admitted one of the processes it set up to help prevent another "Mid Staffs" was "simply not very good".
Richard Hamblin, the CQC's director of intelligence, conceded "engagement forms" to log local intelligence weren't used consistently – as was highlighted in an internal report drawn up by a senior analyst, which was leaked to the Public Inquiry.
The CQC was now introducing a new form called Share Your Knowledge.
"We haven't got as much as we want in and we know that, as we acknowledge. And I have to say that the original form was simply not very good and discouraged people from using it," Mr Hamblin told the Public Inquiry into the Stafford Hospital scandal.
"I think this has about a fifth of the mouse clicks of the original form and is much easier to see and crucially actually shows the information through QRP (quality and risk profile) immediately, rather than requiring, if you like, going into a bit of black hole for a month before it reappears in the model."
Mr Hamblin was on the stand for the second time – as a result of the report compiled by CQC senior operations analyst Rona Bryce which questioned some of the evidence he and other senior managers had given to the Inquiry earlier about the processes in place to identify serious problems within NHS trusts as quickly as possible.
Ms Bryce's review document said there was "evidence that the majority of local intelligence is not being routinely recorded on engagement forms...Therefore the ability to 'spot' Mid Staffs earlier would rest entirely with the judgment of the regional inspector, as the information would not be integrated into the quality risk profile for the organisation".
Mr Hamblin conceded the document, to which regional intelligence and evidence officer Lauren Goodman also contributed, had "some value", but "didn't think it threw up any major concerns about what we'd said (to the Inquiry)...The issue that I acknowledged is the issue of engagement forms being less than perfect."
He was "absolutely convinced that there's a misunderstanding here" and believed "with the exception of the engagement form issue, which I think we have already acknowledged, that the conclusions that were drawn were the incorrect ones. But the process of thinking about what you're doing I think is a very powerful one."
Asked by Tom Kark QC, counsel to the Inquiry, what his reaction had been to the document being leaked, Mr Hamblin said he was "disappointed" because he considered it a "premature document and I felt was giving a misleading impression".
Asked if it was he who had threatened to suspend Ms Boyce at a meeting in August, he replied: "I would not describe it as threatening." Within "five minutes" of the meeting closing, he said he told Ms Boyce there would be no formal investigation and therefore "no question of her suspension".
- The Inquiry resumed on Friday 7 October