Water Safety - CQC Prosecution
The Trust has been prosecuted by the Care Quality Commission under Regulation 12 of the Health and Social Care Act 2008 in relation to its duty to provide safe care and treatment. The prosecution was against the Trust as an organisation, and not any individual member of staff.
We are deeply sorry for the death of Dr Christopher Elliot, a patient under our care in 2022, and for the profound impact this has had on his family. This was a tragedy that should never have happened.
Kevin McNamara, Chief Executive
Kevin McNamara continues: "We extend our sincere condolences Dr Elliot's family - we are deeply sorry for their loss and for the precious time with him that they were denied at such an important moment.
“The Trust entered an early guilty plea and accepted full responsibility for the failings identified, which meant water test results were not shared by our contractor in a timely manner. This would have allowed swift action to be taken by the Trust to restrict access to the room where care was being provided.
“We cooperated fully with the Care Quality Commission throughout its investigation. We had already conducted our own detailed investigation following the incident and shared the findings with the family, regulators and partners.
"We remain committed to being open about what happened and to ensuring that the improvements we have put in place continue to keep our patients safe.”
Water Safety - Frequently Asked Questions
- Since 2022, significant improvements have been made to strengthen water safety, infection prevention, governance and oversight.
- These include clearer processes for responding to risks, stronger monitoring and reporting arrangements, enhanced protection for vulnerable patients, improved staff training, and more robust assurance processes.
- All actions identified through the investigation have since been completed and formally signed off.
- Water safety is managed by Gloucestershire Managed Services (GMS) with day-to-day responsibilities. The Trust has recognised in the CQC prosecution that it retained overall regulatory responsibility for oversight. Strengthening that oversight has been a key focus of the work completed since the incident.
- Patient safety remains our top priority. We have stronger, more consistent systems in place to manage water safety risks, supported by clear procedures, defined accountability and regular audit and review.
- We are committed to being open about what happened, to learning from it, and to ensuring that the improvements we have made continue to protect patients now and in the future.