10 / 03 / 2015
Morecambe Bay investigation: report
Department of Health, 3 March 2015
This independent report, commissioned by the Department of Health and written by Dr Bill Kirkup, investigates failings in maternity care at Furness General Hospital (FGH). It sets out at least seven missed opportunities at “almost every level” which meant poor clinical care was not investigated and led to the preventable deaths of one mother and 11 babies. Kirkup makes a series of recommendations, for both the University Hospitals of Morecambe Bay NHS Foundation Trust and the wider NHS, to prevent such failings happening in future.
The report gives a detailed explanation of the development of the issues at Morecambe Bay, dating back to 2004. Kirkup stresses that “no blame should be attached to staff who make mistakes” but notes that improper investigation of incidents between 2004 and 2007 led to a failure to identify underlying problems. He describes the root causes of the dysfunction in the maternity unit at FGH as substandard clinical competence, poor working relationships, a move amongst midwives to “pursue natural childbirth ‘at any cost’”, failures in risk assessment and care planning, and deficient response to adverse incidents. There was no attempt made to escalate knowledge to the level of trust executives and the board following investigations.
In 2008, following five more serious incidents, the Board commissioned an external investigation, which identified systematic failings. The report describes the maternity unit staff’s reaction to this as amounting to collusion in concealing the truth. A review, published in August 2010 contained “significant criticisms of the Trust’s maternity care”, but was given limited circulation internally and there were delays in sharing it with the North West Strategic Health Authority (NW SHA), CQC and Monitor. The NW SHA “accepted assurances that there were no systematic problems” and “accepted the view that the 2008 incidents were coincidental”.
The Parliamentary and Health Service Ombudsman (PHSO), when investigating a complaint related to the unit in 2009, identified systematic problems and referred these to the CQC. However “failed communications between the PHSO and CQC”, as well as within the CQC resulted in another missed opportunity to investigate. Monitor approved the Trust for FT status in September 2010. In 2011 the situation came to wider attention, resulting in a period of intense intervention and an almost entirely new senior management team in the Trust.
In his conclusions, Kirkup again stresses that individual mistakes should not be subject to criticism due to the nature of healthcare, the real failure here was a lack of proper investigation and a lack of openness and honesty. He notes the isolation of FGH, with recruitment issues and lack of opportunities for joint working allowing clinical practice to “drift” away from standards and procedures. The report describes the Trust’s response when issues reached them as “flawed and inadequate”, potentially attributing this to the focus on achieving Foundation Trust status.
Looking to the wider system, the report notes the “complex and changing landscape” of monitoring and regulation, resulting in uncertainty, upheaval and loss of corporate memory. The failure of NW SHA, the CQC, Monitor and the PHSO to identify and act on the failings is presented as “a collective and individual organisational failure to exercise an effective supervisory or regulatory function”.
Kirkup recommends a series of wide ranging actions to improve University Hospitals of Morecambe Bay NHS Foundation Trust. These include: formal admission of the extent and nature of problems; a review of skills, knowledge and competencies of maternity staff and plans to deliver training and development; measures to promote multi-disciplinary team working; a new protocol for risk assessment in maternity services; an audit of maternity and paediatric services; a new recruitment and retention strategy; development of better joint working between hospital sites; exploring links with a partner trust; a programme to raise awareness of incident reporting; a review of incident investigation and responding to complaints; continued work on clinical governance; ensuring managers are clear on roles and responsibilities for quality; and improvements to the FGH delivery suite. These should be delivered with the involvement of CCGs, the CQC and Monitor.
For the wider NHS, the report recommends:
- Action by the professional regulatory bodies to investigate the conduct of registrants involved in this case.
- A national review of the provision of maternity care in challenging circumstances – this could be broadened out to take in all types of care delivered in “rural, difficult to recruit to or isolated” areas.
- A review of the opportunities and challenges for smaller units.
- The drawing up of clear standards for incident reporting and investigation in maternity services.
- Introduction of a duty of candour for all NHS professionals.
- A duty for all NHS Boards to openly report the findings of external investigations, including promptly notifying the CQC and Monitor.
- Introduction of a clear national policy on whistleblowing.
- Clarification from professional regulatory bodies on the duty of staff to report concerns.
- National standards setting out the duties and expectations for clinical leads at all levels, as well as standards setting out the responsibilities for clinical quality of other managers.
- A national protocol on the duties of trusts and their staff in relation to inquests.
- A fundamental review of the NHS complaints system.
- Effective reform of the Local Supervising Authority system for midwives
- CQC and Monitor to draw up a memorandum of understanding specifying the relationship between their organisations, including roles, relationships and communication.
- A similar memorandum of understanding to be drawn up between the CQC and the PHSO.
- NHS England should draw up a protocol to clarify the potential ambiguity that still exists in the division of responsibilities for oversight of service quality and the implementation of measures to correct failures.
- DH should review how it carries out impact assessments of new policies, as a result of the significant pressures new policies and processes place on management capacity.
- DH should also draw up a protocol on how to manage organisational change that transfers responsibilities and accountabilities.
- Recording systems for perinatal death should be improved.
- A mechanism should be introduced to independently scrutinise perinatal and maternal deaths.
- Reviews of deaths by medical examiners should be extended to stillbirths as well as neonatal deaths.
- Systematic guidance should be drawn up setting out a framework for external reviews, and all external reviews of suspected service failures should be registered with the CQC and Monitor.