The NHS risks creating the conditions for “another avoidable disaster” in care standards, the chair of the Morecambe Bay inquiry has warned.
Dr Bill Kirkup said the lack of progress on implementing recommendations from his report into maternity care failings at the University Hospitals of Morecambe Bay NHS Foundation Trust meant mistakes could be repeated elsewhere.
“Given that we are a year on, it is a disappointing position overall”
He also criticised the national maternity review, commissioned by NHS England, saying it was not a response to his report and that it had not given safety issues in maternity care the attention they deserved.
Dr Kirkup was speaking ahead of the first anniversary of his inquiry into poor care at Furness General Hospital, where failures at almost every level of the NHS contributed to the avoidable deaths of at least 11 babies and one mother.
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Since the inquiry report was published, there has been progress on only 10 of the 26 national recommendations the report had made, he said.
Among the key ones yet to be fully implemented are the introduction of investigations by professional regulators, national reviews into rural isolated services and a review of the NHS complaints system, he said.
“There has been no visible action in some key areas and I don’t think that is appropriate,” he told Nursing Times’ sister title Health Service Journal.
“Given that we are a year on, it is a disappointing position overall,” he said. “Now would be a very good time to take stock publicly and say this is what we have been able to do, this is what we are still to do and this is what we are not going to do.”
Dr Kirkup said he accepted organisations may want to take different approaches than those he recommended, but warned that “just ignoring the problem is not an option – it leaves us in the dark”.
He added: “I think a lot of this is about inertia and the difficulty in managing a very complicated system where you have complex sets of organisations and arrangements. I am also very mindful of the fact that people’s attention is massively consumed by trying to keep afloat, never more so than at the minute, in the midst of winter pressures, with delayed transfers of care and funding that is limited.
“But we ought to be able to focus on more than one problem at a time,” he said. “I do know that it is difficult, but if we don’t do that the worst possible outcome is that we replicate the same mistakes somewhere else and produce another avoidable disaster.”
He highlighted that he did not want the Morecambe Bay investigation “to sit on a shelf untouched”.
National maternity review
Last year Dr Kirkup worked with the national maternity review panel, chaired by Baroness Julia Cumberlege. The review report, which published its findings last month, called for a range of changes to maternity care, including new staffing models, to make them more patient centred.
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- ‘Distressingly’ wide variation in quality of maternity services
Dr Kirkup said that while the work was worthwhile, “it would be wrong to suppose” it was a response to his own findings at Morecambe Bay.
He noted that NHS England had confirmed the maternity review – previously trailed in the NHS Five Year Forward View – in the immediate aftermath of the publication of his report on Morecambe Bay.
“It is very important and has some very worthwhile recommendations in it, but it isn’t the review that was specifically asked for [by us],” he said.
“My disappointment is that… the safety angle has not received the attention it deserves. That underlines the fact that it was not exactly the review that I thought was necessary in the aftermath of Morecambe Bay,” he added.
Dr Kirkup also criticised the “glacial pace” of the Nursing and Midwifery Council and the General Medical Council investigations into staff at Morecambe Bay.
He said: “It’s not good for the people involved because it is hanging over them. It’s even worse for the families who have to go through giving evidence for the umpteenth time in some cases, and a year after the investigation it just brings it all back to the surface. I am very disappointed.
“I have had conversations with both regulators about where I think they ought to look. I have given them everything they need to take it forward,” he said.
James Titcombe, whose son Joshua died after failings at Morecambe Bay, said: “I share the deep frustration and dismay about the lack of progress over the past year. I am especially disappointed in the failure of the NMC and GMC, as well as the trust, to hold anyone accountable almost seven years after Joshua died.
“It is really important that over the next six months substantial progress is made,” he said.
In response to Dr Kirkup’s comments, the Department of Health said it was “absolutely committed” to improving maternity care and NHS England said the national maternity review had set out “comprehensive proposals” on key lessons from Morecambe Bay.
Nursing Times understands the first set of fitness to practise NMC hearings involving midwives from Morecambe Bay will begin next week.