The final person called to give evidence at Sally’s inquest was Susan Wall, an Inspector at the CQC. The coroner had already explained in court that he was not calling Susan Wall to provide any evidence relating to Sally’s death, but to explain the timeline of their action that led to the failed criminal prosecution.

The coroner started by trying to ascertain when CQC first became aware of concerns relating to Sally’s death [Sally died on 27 October 2017].

C: When did CQC first became aware of concerns about Sally’s death?

SW: We received notification from the provider on 27 October 2017 following the death of Sally … was no indication on that notification that there were any concerns in relation to medication for Sally.

Colleague was [can’t hear] …

Looking back on records I can see would then have been some contact with the Safeguarding Team at the Local Authority.

C: So am I right in thinking Worcestershire County Council’s Adult Safeguarding first drew CQC’s attention to concerns in a letter dated 31 January 2018?

SW: I would say it was quite possible it was the Safeguarding Team who drew CQC’s attention, but I suspect was earlier than that from the records I’ve seen.

C: You think CQC would have been aware of concerns before 31 January 2018?

Ms Wall then explained what happened when CQC received concerns about the care Sally had been provided by Dimensions UK.

SW: I’ve seen was an issue between the previous Inspector and Manager to consider whether other people in particular were subject to unnecessary risk, and that triggered an inspection which CQC did in November 2017

C: An inspection of the Dimension’s placement at The Dock?

SW: Not at The Dock, we knew our colleagues in safeguarding were working there at the time, several different addresses where people were cared for … My colleague inspected six different locations, primarily to see whether some of those lessons had been learnt around the management of constipation

C: So it may be by November 2017, a month after Sally’s death, CQC were aware of concerns?

SW: Yes

The coroner asked about the timescale for bringing criminal proceedings, and how and when CQC decided to prosecute Dimensions.

C: Am I right in thinking CQC has a time limit in which to bring criminal proceedings, within 3 years of the person’s death?

SW: Yes

C: The correspondence, perhaps you can tell us, when did CQC actually begin an investigation with view to potential criminal proceedings?

SW: If I can run through the timeline in relation to that. I became the Inspector for Dimensions around May or June 2019

C: What does that mean? You were the first person appointed to consider criminal proceedings or had someone else considered before you?

SW: No. In previous investigation in relation to Sally’s death, prior to that, was seeing if lessons had been learnt, getting assurances other people weren’t exposed to risk, so as an incoming Inspector for that service… [can’t hear] first heard concerns [?] about Sally’s sad death was when we received a bundle from the Coroner’s Office on 6 August 2019

C: That was, I think, in response from a request from you for a bundle of documents?

SW: I can’t remember that. I can remember receiving that bundle on 6^th, what happened then was [can’t hear] Health Management Review with my manager. It decided needed more information at that point.

C: So 6 August 2019 you received?

SW: It may have been sent slightly earlier, and taken a couple of days to go through our national processes, to the individual Inspector

C: It was at that point CQC embarked on an investigation to consider whether criminal prosecution should result?

SW: No. It was in response to this information … and decision was we needed more information…. I started gathering more information in August 2019.

Ms Wall said that in addition to the coroner’s bundle, she made a request for copies of Sally’s care records from Dimensions. She said she also began talking to Dimensions in relation to how Sally’s medicine had been managed.

SW: There was then in November 2019 a meeting which was [can’t hear] meeting to determine whether an investigation should be started in relation to Sally’s death. That happened in November 2019.

The coroner then moved to asking when proceedings were brought, and why it took so long.

C: And I think we received, my office received correspondence from yourselves a year later, 17 November [2020] to say charges would be brought

SW: The decision to prosecute was made from memory around 15 October, and papers to the court on the 19 October [2020]

C: Alright. Can I ask, why it took 2 years, before the CQC considered whether an investigation should be started with a view to criminal proceedings? You were notified of Sally’s death, two years earlier in November 2017.

SW: We were notified definitely in November 2017. I can’t confirm why nothing further was triggered in relation to Sally specifically at that point, I think the focus was very much on seeing whether risks had been mitigated at that point.

C: You had concerns raised by Worcestershire County Council in their letter to you from Adult Safeguarding in January 2018, perhaps even before then?

SW: [Can’t hear]

The coroner then summarised why the criminal proceedings failed and Ms Wall commented on CQC’s disappointment.

C: I think what transpired was, once the criminal proceedings had been brought, a District Judge in the Magistrates Court, ruled in April 2022 those should be stayed as an abuse of process. In effect the finding was the CQC were about to run out of time, and purported to have applied the full test to prosecute, so as to not run out of time, when came to it clearly wasn’t ready for that test to be applied?

SW: We were very disappointed by that judgment. We’d had by the time of our Test Code Meetings, we’d got expert witnesses from our own pharmacy team, our regulatory team, we’d gathered a lot of information directly from Dimensions UK. We’d had further conversations with commissioners, evidence sent to us from commissioners. We thought we had sufficient evidence and it was in the public interest that Sally’s case should be brought.

C: We’re not here to explore that decision, the fact is that decision was upheld by the Administrative Court?

SW: It was

The coroner asked whether CQC were aware of the implications of their proceedings on the inquest process.

C: Is CQC aware a Coroner has discretion as to whether to adjourn inquests if criminal proceedings are brought, with a view to keeping adjourned until criminal proceedings are concluded?

SW: I am yes

C: In this case I exercised my discretion to adjourn this inquest until criminal proceedings were complete, because of the delay and the dealings of the Magistrates Court and then the Administrative Court, that meant this inquest ended up being heard nearly 6 years after Sally’s death, and it’s a little concerning I think to hear CQC didn’t begin any investigation until really 2 years after Sally’s death.

I understand CQC has a number of hats to wear if you like, regulatory but also investigatory. I’m concerned that the CQC understands the ramifications of bringing a criminal prosecution, and the effect it may have on inquest proceedings. That your outstanding, and that the CQC understand if their investigations are delayed that can sometimes have knock on effects on inquest proceedings?

SW: We do understand. In this case reality was we submitted paper for prosecution in October 2020, effectively the whole process wasn’t ended until 23 February this year, that’s a huge delay. We understand in terms of parties concerned, particularly in relation to family, we appreciate that’s caused huge delays to this inquest, unfortunately we don’t set the courts timetable.

C: No, no, no. The delay from start to criminal proceedings until all appeals had run their course, that was because a) the CQC hadn’t applied the full test in time, the courts findings are, Administrative Court findings was the CQC mucked this up, didn’t apply the correct test when they brought proceedings, and they’d purported to do that because they were running out of time, and then took the decision once the Magistrates Court ruled against them, to appeal that and go to the Administrative Court. So I don’t think it’s fair, is it, now matters are determined against CQC to say it’s not our fault, it took all that time for the Courts to decide against us.

SW: All I can say is any decision in relation to this case was made carefully, with due consideration primarily to wanting to get to the truth of what happened. Clearly, if we’ve made mistakes along the way we’re more than happy to address that.

The coroner’s final question is one I’ve been asking myself since proceedings were stayed.

C: So, really what I wanted to ask you is this. Was there any good reason why the CQC investigatory process didn’t start at the same time as their regulatory investigations?

SW: Because I wasn’t the relationship owner at that time, it’s a different manager, I can’t answer that.

C: Alright as an experienced investigator yourself, are you surprised to find in fact the investigation started 2 years after these events, and didn’t start much sooner?

SW: I think that we’d be definitely looking to begin sooner. Balancing the need to make sure other people understood what risks were to other people, at the same time balancing the inspections we do, balancing the fact that actually the inspection and investigation are very different, but sadly the same person. Is potentially a resourcing issue in relation to that, I’d say the Commission has already started to address that, certainly more latterly is a dedicated team to look at investigatory side completely.

C: Is the process in place now that the investigatory team would be starting their business alongside the regulatory team?

SW: Yes, I should say so.

C: Just so I’ve got this clear, you now have a dedicated investigatory team?

SW: [can’t hear] basically an inspector will receive information of concern, will go through channels of do we need more information, do we need to investigate this. At that point once the decision is made to investigate, the evidence gathering and whole investigation will commence, with some input from the inspector.

C: Thank you very much indeed for taking the time, will ask Mr Clarke if he has any questions for you.

Mr Clarke for Sally’s family had no questions, Mr Hassall KC for Dimensions had two questions

CH: You describe the notification Dimension’s made of Sally’s death on the day of her death as an unexpected death report. That’s because that is the type of death that service providers have to report isn’t it?

SW: There are two types, there’s an expected death and an unexpected death. Depending on which type of death it is providers provide the necessary form.

CH: So what was notified to CQC in October 2017 was Sally Lewis has died but we didn’t expect her to do so?

SW: Exactly

CH: You said that by the time it got to August 2019, you were collecting more information that was contained within the Coroner’s Bundle, was sent to you on 6 August, one of the things you did is make enquiries of Dimensions for information they held about Sally?

SW: That’s correct

CH: And Dimensions responded to all of those requests didn’t they?

SW: They did [can’t hear] received most in September, with some amendments.

There were no questions for Ms Wall from Mr Kay KC for Julie Campbell, from Mr Cox for Worcestershire County Council, from Mr Mumford for Dr Williamson, or from her own counsel Ms Wilks.

[I attended the hearings of the failed criminal prosecution of Dimensions and Julie Campbell, the registered manager, and will report on them separately outwith this report of Sally’s inquest. This is my last report from Sally’s inquest, with thanks to my crowdfunders who ensure all my reporting is possible, I’ll try to write something with my thoughts once I’ve given them a little longer to percolate].