Morecambe Bay report exposes 'lethal mix' of failures that led to baby deaths
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Version 0 of 1. A “lethal mix” of failings at almost every level led to the unnecessary deaths of one mother and 11 babies in the maternity unit of a Cumbrian hospital, according to an independent report (pdf). The investigation into deaths at Furness general hospital in Barrow between 2004 and 2013 found maternity services were beset by a culture of denial, collusion and incompetence. Work inside the unit was found to be “seriously dysfunctional”, with poor levels of clinical competence, extremely poor working relationships, and a determination among midwives to pursue normal childbirth “at any cost”. The midwives at Furness general were so cavalier they became known as “the musketeers”. The Morecambe Bay investigation was set up by the health secretary, Jeremy Hunt, in 2013 to examine concerns over what appeared to be a spate of unnecessary deaths within what became the University Hospitals of Morecambe Bay NHS foundation trust (UHMBT). A panel of experts investigated events at Furness general from 1 January 2004 to 30 June 2013. The report’s author, Dr Blll Kirkup, said on Tuesday: “Our findings are stark and catalogue a series of failures at almost every level – from the maternity unit to those responsible for regulating and monitoring the trust. “The nature of these problems is serious and shocking.” Related: Morecambe Bay: Labour and Tories call for new checks on hospital deaths Frontline staff were responsible for “inappropriate and unsafe care” and the response to potentially fatal incidents by the trust hierarchy was “grossly deficient, with repeated failure to investigate properly and learn lessons”. Kirkup said this “lethal mix” of factors had led to 20 instances of significant or major failures of care at Furness general hospital, associated with three maternal deaths and the deaths of 16 babies at or shortly after birth. “Different clinical care in these cases would have been expected to prevent the outcome in one maternal death and the deaths of 11 babies. “This was almost four times the frequency of such failures of care at the Royal Lancaster infirmary,” he said, referring to the other main maternity unit run by the UHMBT. The first warning signs should have been spotted in 2004, the report said, when a baby died from the effects of shortage of oxygen due to a mismanaged labour. An investigation into the death was both “rudimentary” and “over-protective of staff” and failed to identify underlying problems. Between 2006 and 2008 there was a series of further missed opportunities. These included five serious incidents between 2006 and 2007. Each was investigated, but so inadequately that the underlying problems went unnoticed. In 2008, there was a cluster of five serious incidents in the unit. These included a baby who died due to the effects of a shortage of oxygen in labour, a mother who died following untreated high blood pressure, and a mother and baby who died from an amniotic fluid embolism. A baby was damaged due to a shortage of oxygen during labour, while another died from an unrecognised infection. “All showed evidence of the same problems of poor clinical competence, insufficient recognition of risk, inappropriate pursuit of normal childbirth and failures of team-working,” Kirkup said. “Initial investigation was again deficient and failed to identify manifest problems.” The 2008 cluster at least set off alarm bells within the trust. A letter from a consultant obstetrician set out concerns raised by one of the incidents to the clinical director and medical director, but failed to prompt any documented reaction. Furthermore, an external investigation was commissioned following a complaint about another incident that was felt “likely to generate adverse publicity”. Kirkup said the reaction of staff in the maternity was shaped both by a denial that there was a problem and “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 of the significance of hypothermia in a newborn baby.” The disappearance of certain records was of concern to Kirkup and his panel of experts. The investigators found evidence of “inappropriate distortion” in the preparation for an inquest, with the circulation of “what we could only describe as model answers”. The report makes no criticism of staff for individual errors, but condemned incidents of collusion as both “inexcusable” and “unprofessional”. It adds: “The failure to present a complete picture of how the maternity unit was operating was a missed opportunity that delayed both recognition and resolution of the problems and put further women and babies at risk.” The trust’s managers allowed themselves to be distracted by their pursuit of foundation status, Kirkup says. When the healthcare regulator Monitor suspended the trust’s application for foundation status in 2009 it looked to the Care Quality Commission (CQC) “as the arbiter of clinical quality, including patient safety” and highlighted a series of failed communications between the CQC and the office of the health service ombudsman (PHSO). Related: Former CQC deputy chief executive denies Cumbria baby deaths cover-up Crucially, this was at a point in 2009 when the PHSO was considering a complaint from James Titcombe, the father of Joshua, who died in 2008 as a result of an infection missed for almost 24 hours. Officials at both the PHSO and the CQC – which has previously been accused of a coverup over Morecambe Bay – as well as from the local NHS, were among more than 100 individuals interviewed by Kirkup. Kirkup said: “Our conclusion is that these events represent a major failure at almost every level … [There were] repeated failures to be honest and open with patients, relatives and others raising concerns. The trust was not honest and open with external bodies or the public.” Kirkup said the events had been brought to light “thanks to the efforts of some diligent and courageous families who persistently refused to accept what they were being told”. He added: “Those families deserve great credit. That it needed their efforts over such a prolonged period reflects little credit on any of the NHS organisations concerned. “Today, the name of Morecambe Bay has been added to a roll of dishonoured NHS names that stretches from Ely hospital to Mid Staffordshire. “This report sets out why that is and how it could have have avoided. It is vital that the lessons, now plain to see, are learned and acted upon, not least by other trusts which must not believe ‘that it could not happen here’. “If those lessons are not acted upon, we are destined sooner or later to add again to the roll of names.” James Titcombe said he was shocked that midwives at Furness general had been able to act like “musketeers”. “The lack of clinical governance, the fact that these were people protecting themselves, they lost track of mothers and babies and it’s tragic. For me this report really lays out how preventable Joshua’s death was.” “I really recognise now that when we talk about missed opportunities we’re talking in my case about not having a six-year-old boy. “Other families must also have that sense, that after all these things were going wrong nothing was done and other babies were allowed to die. “To err is human, to cover up is unforgiveable.” In a statement, UHMBT said it had apologised unreservedly to the families. Pearse Butler, the chair of the trust’s board said: “This trust made some very serious mistakes in the way it cared for mothers and their babies. More than that, the same mistakes were repeated. And after making those mistakes, there was a lack of openness from the trust in acknowledging to families what had happened. This report vindicates these families. “For these reasons, on behalf of the trust, I apologise unreservedly to the families concerned. I’m deeply sorry that so many people have suffered as a result of these mistakes. As the chair of the trust board, it’s my duty to ensure that lessons are learned and that we do everything we possibly can to make sure nothing like this happens again.” The trust added that the entire composition of its board had changed near the end of the period covered by the report and it recognised the need for improvement in its maternity and neonatal service. It also said it now had 50 more midwives and doctors, and had also improved its culture and team-working. |