Midwives who failed to raise concerns at Furness General Hospital let both themselves and families down and became “victims” of the “closed” culture that they had helped to create, the chair of an inquiry into the trust has told Nursing Times.
Dr Bill Kirkup, who led the investigation into University Hospitals of Morecambe Bay NHS Foundation Trust, said that because midwives failed to speak out about safety issues initially this meant that during later investigations they became “locked into accounts that denied problems”.
“The failure to investigate properly and to be open about what had happened and to learn let the staff down as well as it let families down”
“In the end, the failure to investigate properly and to be open about what had happened and to learn let the staff down as well as it let families down,” the Morecambe Bay Investigation chair told Nursing Times.
“The families had to live with much more drastic consequences, but in the end that same failure did let the staff down,” he said.
His report, published yesterday, noted there were “unequivocal signs of clinical failure in cases going back to 2004” at Furness General maternity unit.
However, these problems were not raised outside of the maternity unit and it wasn’t until after 2008, when a cluster of five serious events – including the death of baby Joshua Titcombe – that concerns were brought to the wider trust’s attention, stated the report.
“There were clear opportunities for the staff in the maternity unit – up to and including the professional heads of the unit – to have looked properly at what happened, to appreciate the systemic problems there and to do something about it, and they didn’t do it,” Dr Kirkup told Nursing Times.
“Staff themselves were to some extent a victim of that inappropriate culture because they then got locked into accounts that denied problems”
He added: “There was a culture around serious incidents which was closed and protective, and about denying problems instead of being open and there being a thorough investigation directed at learning lessons.
“Staff themselves were to some extent a victim of that inappropriate culture because they then got locked into accounts that denied problems,” he said.
Dr Kirkup emphasised clinicians should not be blamed or criticised when something goes wrong in their practice, and should instead be encouraged to be open about the mistake and learn from it.
The point at which staff “cross the line”, he said, is when they fail to be transparent and learn lessons from errors.
When asked about whether there was a risk the events at Morecambe Bay could be repeated in other NHS organisations, Dr Kirkup said that some of the problems contributing to the events would be present at “quite a few” trusts.
He added: “There may also be some [trusts] where there are rather more than a few [problems] – particularly the isolated units that are difficult to recruit to.”
His report included 44 recommendations in total, with 18 suggestions directed at Morecambe Bay and 26 for the wider NHS.
One of the recommendations for the trust is to implement a programme to raise awareness of incident reporting.
Another is to review its policy of openness and honesty in line with the new duty of candour on professional staff – which means they are required to be open with patients and families when something goes wrong.