Following concerns over serious incidents in the maternity department at Furness General Hospital (FGH), the Morecambe Bay Investigation report has now been published. Covering January 2004 to June 2013, the report concludes the maternity unit at FGH was dysfunctional and that serious failures of clinical care led to unnecessary deaths of mothers and babies. The Investigation Panel also reviewed pregnancies at other maternity units run by University Hospitals of Morecambe Bay NHS Foundation Trust. It found serious concerns over clinical practice were confined to FGH.
The investigation report details 20 instances of significant failures of care in the FGH maternity unit which may have contributed to the deaths of three mothers and 16 babies. Different clinical care in these cases would have been expected to prevent the death of one mother and 11 babies. This is almost four times the frequency of such occurrences at the Trust’s other main maternity unit, at the Royal Lancaster Infirmary.
The report says the maternity department at FGH was dysfunctional with serious problems in five main areas:
- Clinical competence of a proportion of staff fell significantly below the standard for a safe, effective service. Essential knowledge was lacking, guidelines not followed and warning signs in pregnancy were sometimes not recognised or acted on appropriately.
- Poor working relationships between midwives, obstetricians and paediatricians. There was a ‘them and us’ culture and poor communication hampered clinical care.
- Midwifery care became strongly influenced by a small number of dominant midwives whose ‘over-zealous’ pursuit of natural childbirth ‘at any cost’ led at times to unsafe care.
- Failures of risk assessment and care planning resulted in inappropriate and unsafe care.
- There was a grossly deficient response from unit clinicians to serious incidents with repeated failure to investigate properly and learn lessons.
The report says proper investigations into serious incidents as far back as 2004 would have raised the alarm. It was not until five serious incidents occurred in 2008 that the reality began to emerge.
Investigation chairman, Dr Bill Kirkup, said: “There was a disturbing catalogue of missed opportunities, initially and most significantly by the Trust but subsequently involving the North West Strategic Health Authority, the Care Quality Commission, Monitor, the Parliamentary and Health Service Ombudsman and the Department of Health.
“Over the next three years, there were at least seven opportunities to intervene that were missed. The result was that no effective action was taken until the beginning of 2012.”
For the Trust, key recommendations include: an apology to families; reviewing skills, training and duties of care; better team working; better risk assessment; an audit of maternity and paediatric services; better joint working across its sites; forging links with a partner Trust; reviewing incident reporting and investigation, complaint handling and clinical leadership; and improving the physical environment of the delivery suite at FGH.
The General Medical Council and Nursing and Midwifery Council are recommended to consider investigating the conduct of those involved in patient care. A national review is also recommended of the provision of maternity and paediatric care in rural, isolated or difficult to recruit to areas.
Other recommendations call for action from Trusts, professional regulatory bodies, the Care Quality Commission, Monitor, the Department of Health, NHS England, nursing and midwifery organisations and the Parliamentary and Health Service Ombudsman. The report concludes that significant progress is being made at FGH.
