It seems highly likely that there are other units that show some of the same care failings found at Morecambe Bay. Assuming that all is well without investigating would be a significant missed opportunity to improve, writes Bill Kirkup
The report of the Morecambe Bay investigation was published on 3 March, and describes the sad and distressing details of a dysfunctional maternity unit and the harm that was caused to mothers and babies.
The report also sets out the catalogue of missed opportunities to detect the problem that extended over at least three years, and involved every level of the system, from the trust itself through the complex and changing NHS regulatory machinery to the Department of Health.
The result was that the same care failures kept recurring, with further avoidable harm to mothers and babies.
I have followed the responses to the report over the last four months or so with interest, and with some concern, mainly because it seems to me that there are some messages there that apply more widely.
If we were to jump too readily to the conclusion that Morecambe Bay was a one-off that has nothing to say about services elsewhere, I believe this would represent another significant missed opportunity to learn and improve.
Whilst overall the response to the report has been encouraging, there are four areas that do cause me concern.
Error and Accountability
In the report, and speaking about it since, I have made two points consistently: error is universal in healthcare, and blame is not only inappropriate, it hinders learning because mistakes are less likely to be reported if people fear blame.
However, some people have extrapolated wrongly from this to suppose that those involved at Morecambe Bay were blameless victims of systems failure.
Public understanding that errors are inherent in all healthcare is very widespread, and it was certainly appreciated by nearly all of the families directly affected by events in the Furness General Hospital maternity unit.
In return for this understanding, however, I believe that all of us who work in and for the NHS owe the public a duty.
‘Some have extrapolated wrongly that those involved at Morecambe Bay were blameless victims of systems failure’
To discharge this duty, we must be open and honest with those affected, and we must investigate the causes and make improvements to prevent the same mistakes being repeated.
When people conceal error or perpetrate cover ups, when they fail to look and learn, when they keep on repeating the same mistakes and cause further harm, they break that unspoken contract.
All of these things happened at Morecambe Bay, many times over a period of years.
Individuals must remain accountable for their side of that contract, and if we try to fudge this as entirely a systems failure we will miss an important point.
Many of the problems in Furness General’s maternity unit stemmed from poor team working, and others went unrecognised for too long partly because of it.
The origin lay in a lack of trust between different professional groups, which then led to a complete breakdown of working relationships between obstetricians, midwives and paediatricians, with disastrous consequences for care.
A lack of trust between professional groups is hardly likely to be confined to Morecambe Bay, and it is a common experience to hear of some degree of mutual suspicion.
‘Healthcare workers largely train and do continuous professional development in isolation from each other’
This may be particularly prevalent in maternity care, because there are at least three groups closely concerned, and because they each have slightly different aims.
If so, it is a significant concern: poor team working can clearly undermine safe and effective care, as happened at Morecambe Bay.
It seems to me that one important factor is that healthcare workers largely train and do continuous professional development in isolation from each other, in tribal professional groupings.
Most other enterprises that depend on teamwork – especially those that are inherently risky – have recognised the wisdom of introducing team working during training, and in maintaining skills and exercising them. It is time that this approach was more widely used in the NHS.
This subject continues to generate intense argument, some of it acrimonious, and some of it referencing Morecambe Bay.
The pursuit of normal childbirth “at any cost” was clearly part of what happened there.
The phrase “at any cost” was not mine, it was said by one of the midwives who saw it in operation in the maternity unit, but the investigation panel saw many instances where this approach clearly underlays inappropriate and hazardous care.
‘The unnecessary loss of a mother or baby is a disproportionate price to pay to avoid asking questions of risk’
In some cases this led to harm, including the unnecessary death of mothers and babies. Tragically, staff in the unit told us that they thought they were doing the right thing to implement a national policy.
I do not believe that we should over-react by trying to medicalise inappropriately what is for the majority a natural physiological and psychological experience.
Equally, however, I do not believe that it is right to suggest, as I have heard said, that we should downplay or even avoid risk assessment in case it “closes down” the experience of childbirth. That would lead sooner or later to avoidable harm.
Another of our interviewees told us that “bad things happen in maternity – people just have to accept it”; but the unnecessary loss of a mother or baby is surely a greatly disproportionate price to pay to avoid troubling people with questions of risk.
It seems to me that we need two things now.
One is a properly informed debate involving public and professionals that is based more on rational consideration of the evidence and less on polarisation and polemic.
The other is clear leadership. As long as messages from senior individuals and professional organisations remain mixed or equivocal, the potential remains for others to think that they too are doing what they are supposed to do by underestimating or ignoring risk, with disastrous consequences sooner or later.
A local problem?
The most worrying remark that I have heard from other trusts following the report publication is “it couldn’t happen here”.
The alignment of almost every single failure from maternity unit upwards that was seen at Morecambe Bay may be inherently unlikely, but it seems highly likely that there are other units that show some of these features, and a few will show more.
The short answer is that it could happen elsewhere, and if we don’t take the trouble to investigate and eradicate the underlying causes then sooner or later it will.
‘I remain confident that we will not duck this significant opportunity’
Given the unnecessary harm that would result, once more would be once too often.
To take the comfortable assumption that all is well without looking would be to miss a significant opportunity to improve an important element of our services.
Overall, I remain confident that we will not duck this significant opportunity, but it does require the right commitment.
Bill Kirkup is chair of the Morecambe Bay Investigation