CQC releases inspection report on the Royal Free Hospital

The inspection was prompted by a high number of never events reported by the provider, the Royal Free London NHS Foundation Trust, in the past year. Never events are serious and largely preventable incidents impacting people’s safety.

Inspectors looked only at the key questions safe and well-led. As this was a focused inspection in response to specific concerns, surgical services were not re-rated and remain requires improvement overall. Safe and responsive remain requires improvement while effective, caring and well-led remain good.

The Royal Free Hospital and Royal Free London NHS Foundation Trust both remain rated requires improvement.

Jane Ray, CQC deputy director of operations in London, said: 

“Following our inspection of surgical services at the Royal Free Hospital, we found people’s safety had been improved by action plans following never events but needed to go further in embedding some changes.

“For example, people’s risk of receiving surgery at the wrong site on their body had been reduced by new processes requiring an increased number of checks by staff. However, though the trust implemented many improvements following incidents, it didn’t always sustain them all.

“People were also placed at preventable risk because leaders didn’t always conduct risk assessments for never events promptly, and leaders didn’t always ensure learning from incidents was shared with all staff.

“We have shared our findings with the trust so they know where improvements must be made and where there is good practice to build on. We’ll continue to monitor the service to ensure people’s safety.”

Inspectors also found:

  • The service had enough staff to keep people safe.
  • Staff were highly focused on people’s individual needs. Most staff felt respected, supported, and valued, and the trust had effectively responded to incidents of poor culture where they had occurred.
  • Leaders understood and ran the service well. They were approachable for staff and people using the service.


  • Medical staff had not always completed mandatory training required to ensure people’s safety. This included training on supporting people with mental health needs, learning disabilities, or autism, which could reduce their quality of care.
  • Staff knew how to recognise and respond to people facing risks of sepsis, but leaders did not ensure results were audited to ensure compliance and identify learning.

The full report can be read here.