Maternity care provided in rural areas and places that are difficult to recruit to needs to be reviewed, according to recommendations made by the investigation into care failings at University Hospitals of Morecambe Bay Foundation Trust.
Such a review should identify requirements to sustain safe services under “challenging circumstances”, said the Morecambe Bay Investigation into avoidable deaths of mothers and babies.
The independent inquiry found the trust’s Furness General Hospital, and its clinical practice, to be “isolated”.
This was partly due to its problems around recruiting and retaining staff, and also a lack of opportunities for shared working.
The inquiry report noted that maternity service in particular had been dependent upon bank and agency midwives, and neonatal nurses during the period covered by the review, from 2004-13.
These factors contributed to practice “drifting” away from accepted standards and procedures, said the inquiry report.
This included declining skills and knowledge, cases of high risk women being undetected, and midwifery care that was “strongly influenced by a small number of dominant individuals whose over-zealous pursuit of the natural childbirth approach led at times to inappropriate and unsafe care”, said report.
It made 44 recommendations in total, with 18 specifically directed at the trust, which included a review of skills and knowledge for all midwifery, neonatal, obstetric and paediatric staff and improved multi-disciplinary working.
In his introduction to the report, investigation chair Dr Bill Kirkup said: “Today, the name of Morecambe Bay has been added to a roll of dishonoured NHS names that stretches from Ely Hospital to Mid Staffordshire.”
He added: “It is vital that the lessons, now plain to see, are learnt and acted upon, not least by other trusts, which must not believe that ‘it could not happen here’.
“If those lessons are not acted upon, we are destined sooner or later to add again to the roll of names,” he said.