Context
NHS Improvement (now absorbed into NHS England) was the UK body responsible for service-level oversight of NHS trusts in 2016. Its contact with the Countess of Chester Hospital NHS Foundation Trust during 2016 is part of the institutional record now documented in the Thirlwall Inquiry evidence bundles.
What NHS Improvement’s remit was
NHS Improvement’s role was regulatory oversight of trusts as organisations: their finances, their governance, their service quality at the trust-level. It did not investigate individual patient deaths. Deaths of specific patients are matters for the coroner and, where suspected criminal, for police referral.
What NHS Improvement did in 2016
In 2016 NHS Improvement had service-level contact with the Trust in connection with the neonatal unit. That contact identified service-level concerns consistent with the picture the Guardian investigation and the Thirlwall Inquiry have since documented in detail: capacity, staffing, governance.
NHS Improvement did not — and could not — investigate the cluster of unexplained deaths as individual cases. That was not within its statutory toolkit.
The three-body external-review package
Trust executives used the combination of:
- The CQC 2016 inspection (service-quality remit).
- The RCPCH 2016 Invited Service Review (unit-configuration remit).
- The NHS Improvement service-level contact (trust-organisational remit).
as rhetorical cover against contacting Cheshire Police. The three-body package functioned as "everything has been looked at" — when none of the three bodies had been scoped to examine individual deaths.
The structural gap
NHS Improvement is part of the same structural gap the CQC page discusses: bodies that inspect services do not investigate individual cases, and bodies that investigate individual cases do not inspect services. The only body with remit to investigate individual deaths is the police — which is what the Trust executive team chose not to engage until May 2017.
Read alongside
Analysis: the CQC 2016 inspection, How the RCPCH review became a decoy, Evidence: chain of escalation.