Your browser is no longer supported

For the best possible experience using our website we recommend you upgrade to a newer version or another browser.

Your browser appears to have cookies disabled. For the best experience of this website, please enable cookies in your browser

We'll assume we have your consent to use cookies, for example so you won't need to log in each time you visit our site.
Learn more

Morecambe midwives became 'victims' of 'closed' culture, warns Kirkup

  • 3 Comments

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”

Bill Kirkup

“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”

Bill Kirkup

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.

  • 3 Comments

Readers' comments (3)

  • michael stone

    '“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.

    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.'

    I was listening to one of the parents on BBC Radio 4 recently, and he said when the parents raised concerns, they were (it subsequently became clear) lied to by the Trust - just like Mid Staffs.

    SOMEHOW the NHS needs to get to:

    '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.'

    Because Dr Kirkup is right about what really angers the service users after 'distressing things happened':

    'The point at which staff “cross the line”, he said, is when they fail to be transparent and learn lessons from errors.'

    Unsuitable or offensive? Report this comment

  • 'Twas ever thus - certain sections of the NHS have created systems designed to insulate themselves from knowledge of many things and thus to avoid the need to act upon that knowledge. But it takes a Furness or a Mid-Staffs or a Roycroft to get people in authority to begin to look at that...

    https://grumblingappendix.wordpress.com/2015/02/24/something-rotten-in-the-state-of-denmark/

    https://grumblingappendix.wordpress.com/2014/12/11/plausible-deniability/

    Unsuitable or offensive? Report this comment

  • michael stone

    BasketPress | 6-Mar-2015 10:02 am

    Hi Basket - I wrote 'SOMEHOW' because I have no idea how to get from where we are, to where the NHS 'ought to be', on this one.

    Can you fill in the 'somehow', or are you stumped by the problem like I am ? I think proper protection for anybody who raises a concern, is the place to start (so, 'Francis' then). Just saying 'the culture has to change' isn't, to my mind, explaining how change is to be effected.

    Unsuitable or offensive? Report this comment

Have your say

You must sign in to make a comment

Please remember that the submission of any material is governed by our Terms and Conditions and by submitting material you confirm your agreement to these Terms and Conditions. Links may be included in your comments but HTML is not permitted.