National standards need be drawn up for incident reporting in maternity settings, according to the investigation into care failings at University Hospitals of Morecambe Bay Foundation Trust.
Morecambe Bay Investigation into avoidable deaths of mothers and babies at the trust found it had failed to provide sufficient detail of complaints in its reporting.
The inquiry also found there was a “distortion of the truth in responses to investigation, including particularly the supposed universal lack of knowledge of the significance of hypothermia in a newborn baby”.
It said “in this context, events such as the disappearance of records, although capable of innocent explanation, concerned us”.
“Professional regulatory bodies should clarify and reinforce the duty of professional staff to report concerns about clinical services”
A national protocol setting out the duties of trusts and staff when taking part in inquests should also be drawn up, according to the investigation report, which it said should include a mandatory requirement that staff are not coached in what answers to provide.
This followed evidence uncovered by the inquiry of “model answers” being circulated to staff ahead of an inquest.
Meanwhile, the investigatory report commended the introduction of the duty of candour for all NHS workers and the introduction of a national policy on whistleblowing.
It added: “Professional regulatory bodies should clarify and reinforce the duty of professional staff to report concerns about clinical services, particularly where these relate to patient safety, and the mechanism to do so. Failure to report concerns should be regarded as a lapse from professional standards.”
The report also highlighted the “ineffectual” system of statutory supervision for midwives identified at the trust – which often involved a conflict of interest for a midwife who was both a risk manager and supervisor.
“Every midwife and nurse has a responsibility to speak up when things go wrong”
It said that while it was not within its remit to examine this system nationally, it believed this problem was not unique to the trust and called for an “urgent response” to a recent King’s Fund report that recommended the system be reformed.
Jackie Smith, chief executive and registrar of the Nursing and Midwifery Council, said: “Every midwife and nurse has a responsibility to speak up when things go wrong and the work we are doing with the General Medical Council on the duty of candour will reinforce that duty to speak up.
She added that she was “pleased” the inquiry had acknowledged the need to remove supervision from the regulator’s legislation.
“With the necessary and long overdue changes to our legislation, we can make further improvements,” she said.