The CQC 2016 inspection — what the regulator found, and why it didn't find more
Prosecution claim
The institutional narrative at trial included the claim that external regulators and reviewers had 'looked at' the cluster of deaths during 2016 and had not identified deliberate harm. The CQC's 2016 inspection is one of the external touchpoints cited.
Counter-evidence
The Care Quality Commission's statutory remit is the quality and safety of services. It does not investigate individual patient deaths — if a death looks suspicious, the CQC refers it to police or the coroner. The 2016 inspection of the Countess of Chester identified service-level concerns about capacity, staffing and governance, consistent with the 'unit beyond its envelope' picture the Panel and the Guardian investigation later documented in more detail. The inspection did not examine individual death cases because that was not its remit. Trust executives subsequently used the CQC touchpoint as part of a rhetorical package — 'everything has been looked at' — when no body with the remit to investigate individual deaths had in fact been engaged.
The CQC does services. The police do individual deaths. There is a structural gap between them, and in 2016 the Countess of Chester's executives used that gap as a reason not to escalate.
What the jury heard
The CQC inspection was part of the institutional-response narrative presented at trial. The specific limits of the CQC's remit were not systematically walked through.
What the Panel says
The Panel's remit is medical, not regulatory, but its finding that medical evidence of deliberate harm is absent is consistent with the CQC's own finding that the unit's problems were systemic rather than individual-actor.
What independent experts add
- The CQC's 2016 inspection rated the Trust with specific concerns about the neonatal unit's capacity and governance.
- The CQC did not investigate the cluster of deaths because investigating individual deaths is not within its remit.
- The RCPCH Invited Service Review in the same year was also scoped to service-level questions, not individual deaths.
- NHS Improvement / NHS England oversight contacts in the same period were also scoped to Trust-level rather than case-level concerns.
- The three-body external-review touchpoint package (CQC, RCPCH, NHS Improvement) gave executives rhetorical cover to avoid the one body — Cheshire Police — whose remit did include investigating individual deaths.
- Sue Eardley's Thirlwall Inquiry evidence addressed the structural gap in NHS oversight where service-level and individual-level review do not meet.