Exclusive: PHSO's capability questioned after Morecambe Bay report

Concerns were raised after the Kirkup inquiry’s conclusions contradicted a PHSO investigation last year on the question of whether Morecambe Bay midwives colluded over evidence to an inquest.

The Kirkup inquiry said there was “clear evidence of distortion of the truth” by midwives, describing how they were given a crib sheet of “model answers” before the inquest into the death of Joshua Titcombe, who died as a result of failings at Morecambe Bay in October 2008.

This came a year after ombudsman Dame Julie Mellor said she found no proof that the midwives colluded over evidence. She said she saw no evidence of “professional wrongdoing” by midwives ahead of the inquest taking place.

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The PHSO, which is the final arbiter of patient complaints in the NHS, initially issued a statement to HSJ from its managing director Mick Martin in which it stood by its investigation and said the Kirkup inquiry had not questioned its findings.

However, the PHSO this morning decided to revise its statement. HSJ has learned that the change of tack came after the direct intervention from Dr Kirkup.

In the new statement to HSJ, Mr Martin said: “We fully support the report and agree with the findings. Dr Kirkup has provided a comprehensive account of the failings at [the trust].

“The Morecambe Bay investigation had access to more evidence, including a range of interviews and over 15,000 documents from 22 organisations and therefore it’s not surprising that he reached different conclusions. We only reached different conclusions on the preparations made for the inquest.”

Speaking to HSJ, Dr Kirkup said: “I was surprised when I saw the first statement.”

He added: “The Morecambe Bay investigation findings are based on a careful and thorough review of a great deal of documentary evidence and I am sure our conclusions are robust.”

The inquiry said a meeting with the trust solicitor before the inquest was “entirely in order and appropriate” but added: “What happened next, however, was clearly wrong: Jeanette Parkinson, the maternity risk manager and senior midwife, prepared a single set of what we can only regard as ‘model answers’ to the questions, and circulated them to all of the midwives involved.

“This distortion of the process underlying an inquest was picked up by the coroner, who commented on the similarity of the accounts that he heard from different witnesses and the concern that this caused him.”

The Commons public administration committee is currently investigating the handling of NHS complaints and clinical incidents.

Committee chair Bernard Jenkin said he was concerned at the differences between the Kirkup inquiry and the PHSO investigation, saying: “There is absolutely no dispute that there is a lack of capacity for immediate, objective, independent and confidential investigative capacity into clinical incidents. The capacity simply does not exist and there is confusion about who is responsible for what.

“The PHSO was never set up with clinical incident investigations in mind. It is not a system we are going to recommend that patient safety relies on.”

James Titcombe, father of Joshua and whose campaigning led to the Kirkup inquiry taking place, told HSJ: “If it wasn’t for the Kirkup inquiry the decision of the Ombudsman would have been the final word. It would have vindicated the individuals involved and their behaviour as well as reinforce the poor culture.

“That is the opposite of what the PHSO is supposed to do and increases the chance the same thing will happen again. It is dangerous and only a few weeks ago the Ombudsman said in a statement that they stood by the quality of their investigations.

“The actions of the PHSO are disgraceful. They have revised their statement only after Bill Kirkup intervened. I think Dame Julie should consider her position.”