Many positive changes have been made at the trust but many of the inquiry’s recommendations remain worryingly unaddressed, write Bill Kirkup and James Titcombe

Two years ago today, we were in an auditorium in the small coastal town of Grange-over-Sands in Cumbria, waiting for an event of great importance for both of us. This was the culmination of a complex and often harrowing two-year investigation into failures at Furness General Hospital between 2004 and 2013.

One of us would be presenting the findings to the public, the trust and the families directly affected by what had happened. The other was waiting for the moment, along with other families, to hear at last a truthful account of events that involved very painful and personal loss and a lengthy and difficult struggle to make sense of what happened.

The findings of the investigation were serious and stark. There was a catalogue of failures at almost every level, from the maternity unit to those responsible for regulating and monitoring the trust. A lethal mix of factors led to 20 instances of significant or major failures of care, associated with three maternal deaths and the deaths of 16 babies. Different clinical care in these cases would have been expected to prevent the outcome in one maternal death and the deaths of 11 babies.

The trust has made significant progress in terms of changing the culture in maternity services, ensuring that staff work together as one team and improving processes to ensure that when things do go wrong, incidents are properly investigated

The report made 44 recommendations for change. The first 18 were specifically for the Morecambe Bay Trust itself, with the remainder aimed at the wider system. Two years after the publication of the report, we have reflected together on what has happened since, where progress has occurred and where necessary change still lags behind.

Remarkable local change

The changes within the Morecambe Bay Trust itself have been impressive. It would have been easy to see the investigation report as another negative to be fended off, but they have worked hard not only to implement the report recommendation, but to go further in terms of changing culture and improving the quality of care across the organisation. Today, the Morecambe Bay Trust as a whole is clearly transformed from where it was two years ago.

The positive progress is most clearly evidenced by the most recent CQC report which gave it a “good” rating overall with an “outstanding” rating for caring. The trust has also invested in the construction of an £11m maternity unit which will be completed later this year.

The trust has made significant progress in terms of changing the culture in maternity services, ensuring that staff work together as one team and improving processes to ensure that when things do go wrong, incidents are properly investigated and recommendations made and acted on.

This has required leadership and commitment, and the results have been worth it. Maternity services elsewhere could benefit by learning from the changes made at Morecambe Bay.

The establishment of the new Healthcare Safety Investigations Branch

Given that so much time and effort was required at the start of the Morecambe Bay Investigation to establish a framework and methodology, the report’s final recommendation was for a new national framework for future similar investigations. Since the report was published, the government has accepted recommendations following a report from the Public Administration Select Committee (PASC), calling for a new national independent patient safety investigation body.

The establishment of HSIB should mean that systemic failures such as those that occurred at Morecambe Bay would be investigated much sooner in the future. Better, HSIB could play an important role in helping to demonstrate and spread best practice in investigations across the MHS, preventing such problems from becoming as entrenched in future.

Government ambition to halve the rate of stillbirths and infant deaths by 2015

In November 2015, the government announced a new ambition to reduce the rate of stillbirths, neonatal and maternal deaths in England by 50 per cent by 2030. The announcement included a fund of £4m to support trusts to buy improved digital equipment and to provide training for staff already working to improve outcomes for mothers and babies.

Further funds have been set aside to develop a system for improved perinatal mortality review and multidisciplinary training. We welcome and support these measures, and the supporting Royal College of Obstetricians and Gynaecologists programme Each Baby Counts, to tackle an important and previously under-recognised area.

Whilst there has clearly been significant progress in these key areas, some of the national recommendations have not been implemented and in others, the pace of change has been disappointingly slow.

Professional regulation

The first national recommendation was for the professional regulators to review the findings of the report and with a view to investigating further the conduct of individuals. The Nursing and Midwifery Council was desperately slow to begin working on this and still has one case outstanding.

Another was described as “deficient” by the Professional Standards Authority. In our view, much of the focus has been misdirected to looking for deficient clinical practice, when the more significant issue was the failure to admit error, the cover-ups, and the falsification that followed incidents, preventing learning and turning clinical error into systematic service failure. The result has been unsatisfactory for all concerned.

The provision of maternity services in challenging and rural areas

The investigation report recommended a review of the provision of maternity services in challenging areas nationally, including in areas that are rural, difficult to recruit to, or isolated. The government refers to the National Maternity Review published in March 2016 as the response to this recommendation. Whilst the review made many helpful and far-reaching recommendations, it did not tackle head on the difficult problem of the sustainability of services necessary in problematic locations. This is not a response to the investigation’s recommendations on isolated maternity or other services.

Clear standards for incident reporting and investigation in maternity services

There is inexplicable variation in incident reporting and investigation by maternity services nationally, and the Morecambe Bay investigation recommended clear standards for incident reporting and investigation, including the mandatory reporting and investigation of serious incidents of maternal deaths, late and intrapartum stillbirths and unexpected neonatal deaths.

Whilst it makes sense to place the work of developing these standards with HSIB, the decision meant that nothing has happened yet pending the establishment of the new branch. The standards are still awaited two years on.

National protocol on inquests

Many trusts still treat inquests defensively in prospect, as an exercise in reputation management, and as a safety investigation retrospectively. They should be neither. The legal resources often deployed at public expense by trusts can seem unfair and intimidating to bereaved relatives. This imbalance makes it important that NHS organisations behave ethically and reasonably during inquests, and treat them as the fact-finding process that they should be.

The investigation report recommended a national protocol setting out the duties of all trusts and their staff in relation to inquests. It is disappointing that this recommendation has not been progressed.

Medical examiners

The Morecambe Bay Investigation was the latest in a long series to highlight the lack of an effective mechanism to scrutinise deaths independently and to recommend the introduction of a system of medical examiners. We welcome the signs of belated progress on the implementation of this system, which will act as an effective backstop. It is, however, disappointing that stillbirths will be outside the scope of medical examiners. Although there are legislative reasons for this omission, we believe that this is a significant missed opportunity to bring stillbirths into line with scrutiny of other deaths.

The balance of risk and focusing on minimising interventions in childbirth

Perhaps the most difficult lesson of all from events at Morecambe Bay was the way in which the inappropriate pursuit of protecting normality in childbirth was allowed to put mothers and babies at significant risk in the unit. Understandably, this finding caused concern, distress and even doubt, but the evidence was clear and unmistakable. Tragically, staff told the investigation panel that they thought they were doing the right thing to implement a national policy.

For the majority, childbirth is a natural physiological and psychological process, and we do not believe that it should be medicalised. But it can and does go wrong from time to time, and it is vital that staff are able to recognise signs of departure from normality and are ready to act appropriately.

As well as the necessary skills and training, this requires the right mindset. It also requires good working relationships between staff groups, particularly obstetricians and midwives. It is clear that in some units around the country, working relationships are still far from ideal. If teamwork is allowed to continue to deteriorate, the end point is there to see in the events at Morecambe Bay.

In conclusion, we have been greatly encouraged to see the good work that has followed publication of the report, and we commend the trust particularly for its success. However, we remain concerned that gaps remain in the response to the wider recommendations. One Morecambe Bay maternity disaster is more than enough.

James Titcombe OBE became involved in patient safety following the loss of his baby son due to failures in his care at Morecambe Bay Trust in 2008. Bill Kirkup was appointed chair of the Morecambe Bay Investigation in July 2013.