“Serious and shocking” failures at almost every level, from the maternity unit to regulators, resulted in the unnecessary deaths of mothers and babies over a series of years at University Hospitals of Morecambe Bay NHS Foundation Trust, a major investigation has found.
An independent inquiry, which looked at events at the trust from January 2004 to June 2013, found evidence of “substandard” clinical competence, “deficient” skills and knowledge and “extremely poor” working relationships between staff groups such as midwives, paediatricians and obstetricians.
“There was a disturbing catalogue of missed opportunities, initially and most significantly by the trust”
It also identified a “growing move” among dominant midwives to pursue natural childbirth “at any cost”, which led to unsafe care and a “grossly deficient” response by the trust to adverse events, with repeated failure to investigate.
It said this “lethal mix” of problems originated in the “dysfunctional” maternity service at the trust’s Furness General Hospital.
The panel behind the Morecambe Bay Investigation, which was chaired by Dr Bill Kirkup, found 20 instances of significant or major failures of care at the hospital, which could have contributed to three maternal deaths and 16 baby mortalities.
One mother and 11 babies could have been prevented from dying if they had been given different clinical care, the investigation concluded.
The inquiry said lessons must be learned to both improve the safety of maternity services and also reduce the risk of similar events occurring elsewhere in the NHS.
It has made 44 recommendations in a report published today.
These include that the trust should review the skills and knowledge of all midwifery, neonatal, obstetric and paediatric staff by June 2015, by which time necessary training and possible experience elsewhere should be arranged.
Measures for multi-disciplinary working should also be put in place and an audit for the operation of its maternity and paediatric services should be carried out.
A recruitment and retention strategy should also be identified to achieve a “balanced and sustainable workforce” and to encourage development of specialist practice, while a review of clinical leadership should be undertaken.
Incident reporting should also be addressed and the trust’s policy of openness and honesty must be reviewed in line with the duty of candour standards, said the panel.
The investigation has also called for the trust to formally admit the extent and nature of the problems and to issue an apology to families affected for both the avoidable damage it caused and the length of time it took to investigate them.
Dr Kirkup said: “For the first time the full extent of the problems have been laid bare, independently and comprehensively.
“Those affected by the consequences deserve to see the nature and degree of failures acknowledged, after too long hearing them denied. I am sorry that it has taken so long to happen,” he said.
“I would like to thank the families who have been harmed by these events,” he said. “Without their courage in coming forward and their persistence in challenging what they were wrongly told, this investigation would not have come about.”
Dr Kirkup added: “There was a disturbing catalogue of missed opportunities, initially and most significantly by the trust but subsequently involving the North West Strategic Health Authority, the Care Quality Commission, Monitor, the parliamentary and Health Service Ombudsman and the Department of Health.
“Over the next three years, there were at least seven opportunities to intervene that were missed,” he said. “The result was that no effective action was taken until the beginning of 2012.”
The investigation was commissioned by the Department of Health in September 2013 to look into the safety of maternity and neonatal services at University Hospitals Morecambe Bay NHS Foundation Trust.
A series of deaths that occurred in the maternity and neonatal services unit at Furness General became the focus of a long-term campaign by those affected.
The independent investigation has focused on the actions, systems and processes of the Morecambe Bay trust as well as the actions of regulators and commissioners. It also heard from those involved and their relatives and clinicians, managers and regulators.
Under the investigation’s terms of reference, Dr Kirkup and his panel were asked to make findings on the “adequacy of the actions taken at the time by the trust to mitigate concerns over safety” and its ability to discharge its duties in delivering maternity services.
In addition, they were to make recommendations on the lessons to be learned for both the trust and the wider NHS to secure the delivery of high quality care.
The publication of its findings have been delayed twice before, having originally been scheduled for last July.
In September last year, it emerged more than 200 deaths of mothers and babies at the trust had been investigated, with over 50 cases identified for detailed analysis.
The Nursing and Midwifery Council is currently deciding whether eight midwives who formerly worked for the foundation trust should face disciplinary action.