The independent inquiry into events at University Hospitals of Morecambe Bay Foundation Trust has found ‘failures at almost every level of the NHS’ combined to create a ‘lethal mix’ which caused the avoidable deaths of at least 11 babies and one mother.
As well as failings among a cadre of midwives known as “the musketeers”, the inquiry, chaired by Bill Kirkup, also found widespread failings by regulators.
The inquiry report (see related files, right) said regulators relied on “mutual reassurance concerning the trust that was based on no substance”, with repeated and significant missed opportunities to spot serious incidents, deaths and poor care.
In a similar way to the failings previously revealed at Mid Staffordshire Foundation Trust, the inquiry said the focus on Morecambe Bay’s efforts to achieve foundation status “played a significant part in what transpired”.
The trust’s FT application had been put forward to Monitor for consideration in 2009 by the health secretary, but Monitor deferred the decision due to concerns.
Subsequent to this, changes were made to the FT authorisation process – to make it more sensitive to governance of care quality – in response to revelations about the Mid Staffordshire scandal.
However, Morecambe Bay was then granted foundation status in 2010, not having gone through the changed process. Dr Kirkup’s report states that the DH considered whether the new process should apply, and received legal advice that it should not intervene, as the health secretary had previously put the application forward.
The inquiry, which examined 15,280 documents from 22 organisations and took evidence from 118 people, said problems at the trust started because of the “seriously dysfunctional nature of the maternity service at Furness General Hospital”. It said the clinical competence of staff was “substandard” with staff having “deficient skills and knowledge” and there were poor working relationships between obstetricians, paediatricians and midwives.
It said there “was a growing move amongst midwives to pursue normal birth at any cost” which ultimately led to “inappropriate and unsafe care”. The inquiry called the response to concerns “grossly deficient”, with repeated failure to investigate properly and learn lessons.
It said: “Together, these factors comprised a lethal mix, that, we have no doubt, led to the unnecessary deaths of mothers and babies.”
The report concluded there were 20 incidents of significant failure with three maternal and 16 infant deaths, and said different clinical care would have been expected to prevent the deaths of 11 babies and one mother.
The inquiry found the failures at the unit “must have been clear to senior and experienced unit staff” but it added: “We found no attempt to escalate knowledge of this to the level of trust executive and board.”
It said the staff reaction to concerns was “shaped by denial that there was a problem” and rejected criticism, which turned into hostility. It went on to describe “a strong group mentality amongst midwives characterised as ‘the musketeers’”.
“We found clear evidence of distortion of the truth in responses to investigation, including particularly the supposed universal lack of knowledge over hypothermia in a newborn baby, and in this context the disappearance of records… concerned us.”
It also said there was evidence inappropriate preparation for an inquest “with circulation of what we could only describe as model answers”.
While the report said staff should not be blamed for errors, it added “where individuals collude in concealing the truth of what has happened… their behaviour is inexcusable as well as unprofessional”.
James Titcombe, who campaigned for the Kirkup inquiry after his son Joshua died as a result of failings at Morecambe Bay in October 2008, told HSJ: “I am deeply shocked at the scale and seriousness of what happened but I welcome the report which I feel exposes the truth and which could lead to important changes for patient safety.
“It is appalling how the system acted to put up obstacles at every step and made it almost impossible to explore the issues and incidents which we knew had happened.
“The NHS should never have to hold these kinds of inquiries to get to the truth.”
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Morecambe Bay inquiry reveals 'lethal mix' of failings