CQC reaction to coroner’s verdict on the death of Ebony McCall at Milton Keynes Hospital NHS Foundation Trust

Published: 11 December 2009 Page last updated: 12 May 2022

11 December 2009

Amanda Sherlock, deputy director of frontline operations at the Care Quality Commission, today (Friday) welcomed the deputy coroner's thorough investigation of the events leading to the tragic death of Ebony McCall.

CQC will consider his findings as part of a follow-up report on Milton Keynes Hospital NHS Foundation Trust maternity unit, which will take account of information about performance and recent inspection.

The report will review progress made by the trust against 12 recommendations for improvement published by CQC's predecessor, the Healthcare Commission, in December last year.

Among concerns was that a lack of sufficient resources, principally in the number of midwives in post and in the provision of bed capacity, was placing a risk to the safe delivery of maternity services.

Ms Sherlock said: "The death of Ebony is an absolute tragedy.

"The trust must learn and do everything possible to ensure the same thing does not happen again. It is clear that the unit was insufficiently prepared to cope with the pressures on that particular night and that Ebony did not get the care she needed as a result.

"We do believe there have been improvements since last year's assessment, in particular in the areas of clinical governance and leadership. But we are absolutely clear that more needs to be done, particularly in the areas of increasing numbers of midwives and learning from serious incidents.

"The trust must respond quickly on all of the recommendations. While care has improved in some areas, faster improvements need to be made in other parts of the service. It must get its procedures right every day, for every mother and baby. It must plan for high levels of demand and ensure it has systems in place to cope at all times.

"We would not hesitate to take further action if we felt it were necessary. We will be reporting in full on the findings of our recent inspection and assessment activity. We will continue to closely monitor progress together with key partners including the PCT, SHA and Monitor, until we have full reassurance on all the concerns raised by the coroner."

Ends

For further information please contact the CQC press office on 0207 448 9401 or out of hours on 07917 232 143.

Notes to editors

About the CQC: Snippet for press releases

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.


We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.


We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.

Find out more

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.