Morecambe Bay review: Hunt backs independent safety investigation unit

Jeremy Hunt made the call this afternoon in response to the Kirkup investigation into maternity care failings at Furness General Hospital, which he dubbed “a second Mid Staffs”.

Speaking in the Commons today following the Kirkup report’s publication, Mr Hunt said: “There is no greater pain than for a parent to lose a child, and to do so knowing it was because of mistakes that we now know were covered up makes the agony even worse.

“In short, it was a second Mid Staffs, where the problems, albeit on a smaller scale, occurred largely over the same time period.”

Mr Hunt said he would immediately ask NHS England’s national director of patient safety Mike Durkin to look into the possibility of creating an independent patient safety investigation unit along similar lines to the air accidents branch - a part of the Department for Transport.

Mr Hunt said incident investigations would continue to be instigated and carried out locally, but trusts would be able to draw upon the assistance of an “expert independent national team to establish facts rapidly on a no blame basis”.

Dr Durkin will also be charged with drawing up “much clearer guidelines” for standardised incident reporting.

The health secretary said evidence from the Kirkup inquiry suggesting medical notes had been destroyed and mistakes covered up showed there was “a long way to go” in improving openness and transparency.

He said he would ask Sir Bruce Keogh, NHS England’s medical director, to review the professional codes of doctors and nurses “to ensure that the right incentives are in place to prevent people covering up instead of reporting and learning from mistakes”.

Mr Hunt said the government would develop and legislate for a “more effective oversight arrangement” for midwifery supervision, with proposals on the new system due by the end of July.

He said the Nursing and Midwifery Council would go through the evidence gathered by the investigation, and that anyone found to have practiced unsafely or to have covered up mistakes would be held to account.

He added the NMC would “not hesitate” to pass information to the police if they found evidence suggesting a criminal offence may have been committed.  

Mr Hunt said the government would examine the 44 Kirkup recommendations “in detail” before providing a full response, but added that he expected Morecambe Bay to implement all 18 of the recommendations made for the trust.

Andy Burnham, the shadow health secretary, said Labour supported all the recommendations from the report and that the government could rely on the party’s “full support in introducing them at the earliest opportunity”.

He announced a Labour review would look at introducing mandatory review of case notes for every hospital death in England.

It would receive advice from Nick Black of the London School of Hygiene and Tropical Medicine, who has also advised the government on hospital mortality, and is due to be completed next month.

Mr Burnham said: “The report recommends mandatory reporting and investigation as serious incidents of all maternal deaths, still births and unexpected neonatal deaths.

“But isn’t there a case to go further, including looking at how we can move to a mandatory review of case notes for every death in hospital, and also looking at how we can use a standardised system of case note review to support learning and improvement in every trust,” he added.