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CQC and PHSO memorandum of understanding

Morecambe Bay Investigation · Report of the Morecambe Bay Investigation · Issued 3 March 2015 · Addressed to: CQC

Government responseDepartment of Health and Social Care: Accepted (Jul 2015)

DeliveryDHSC and NHS England say completed (Feb 2026)Department of Health and Social Care says in progress (Feb 2020)

Recommendation, verbatim from the inquiry

●Inquiry recommendation

The relationship between the investigation of individual complaints and the investigation of the systemic problems that they exemplify gave us cause for concern, in particular the breakdown in communication between the Care Quality Commission and the Parliamentary and Health Service Ombudsman over necessary action and follow-up. We recommend that a memorandum of understanding be drawn up clearly specifying roles, responsibilities, communication and follow-up, including explicitly agreed actions where issues overlap. Action: the Care Quality Commission, the Parliamentary and Health Service Ombudsman.

Morecambe Bay Investigation, Report of the Morecambe Bay Investigation · 3 Mar 2015 Source PDF →

Published evidence summary

AI-generated evidence summary

In commentary of September 2024, published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was implemented and closed, stating that arrangements, including a memorandum of understanding, are in place between the Care Quality Commission and the Parliamentary and Health Service Ombudsman (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).

AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026.

Government response

●Department of Health and Social Care · Accepted · 16 Jul 2015

Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015

90. We accept this recommendation. The Investigation found that the lack of co- ordination between the Care Quality Commission and the Parliamentary and Health Service Ombudsman was a contributory factor to the ongoing inability of the wider system to identify and act on failings at the Trust. A new Memorandum of Understanding between the Care Quality Commission and the Parliamentary and Health Service Ombudsman was signed in September 2013 which outlined how the two organisations will collaborate, co-operate and share information relating to their respective roles. 91. We have asked the Care Quality Commission and the Ombudsman to keep this Memorandum of Understanding under regular review and to keep it up to date.

Response document: Learning not blaming: The government response to the Freedom to Speak Up consultation, the Public Administration Select Committee report 'Investigating Clinical Incidents in the NHS', and the Morecambe Bay Investigation

Site note: This is the Department of Health's response, "Learning not blaming" (Cm 9113, July 2015), to the Morecambe Bay Investigation and two other reports. The department has been the Department of Health and Social Care since January 2018, and the rows are filed under that name. Every word is the department's, including where it reports what another body has done or will do.

Site note: The recommendation is addressed to the Care Quality Commission; the passage is the Department of Health's account, not that body's.

Delivery

●DHSC and NHS England say completed · 27 Feb 2026

The Thirlwall Inquiry has noted action taken in response to this recommendation. Arrangements, including an MoU, are in place between CQC and PHSO.

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025)

Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Implemented – Closed”. Table row: section 23.2 No. 34, PDF page 651-652.

●Department of Health and Social Care says in progress · 27 Feb 2020

The Care Quality Commission (CQC) has a Memorandum of Understanding (MoU) in place with the Parliamentary and Heath Service Ombudsman (PHSO). The MoU sets out the framework for the working relationship between the two organisations.

In addition, the CQC and the PHSO are working on a more direct means of sharing final PHSO investigation reports and are drafting an outline information sharing agreement for this purpose which will be published in due course.

From: Care Quality Commission: Parliamentary and Health Service Ombudsman (written question UIN 19793)

Site note: Written answer of 27 February 2020 by Nadine Dorries for the Department of Health and Social Care. The question cites the Morecambe Bay Investigation report and asks what has been done on this recommendation. The recommendation is addressed to the Care Quality Commission and the Parliamentary and Health Service Ombudsman; this is the Department's answer, not theirs.

What other bodies have found

In their own words. These do not change the delivery statement above.

●Thirlwall Inquiry legal team · 15 May 2024

Department of Health response (July 2015):

Accepted.

“A new Memorandum of Understanding between the Care Quality Commission and the Parliamentary and Health Service Ombudsman was signed in September 2013 which outlined how the two organisations will collaborate, co-operate and share information relating to their respective roles.” (p. 88)

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024)

Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review colours its Extent of Implementation cell for this recommendation green, which it uses to mark evidence, identified by the legal team, that a recommendation has been clearly implemented. Table row: section 20.2 No. 34, PDF page 616.

How this page is built

The recommendation and the government responses are verbatim from primary documents. Delivery statements and other bodies' findings are shown in their own words, each with its source. The summary is written by this site and labelled as such. The Index does not paraphrase sources or characterise intent; it records what has been published.