Major failings at a hospital and by wider health authorities means the deaths of mothers and babies were not properly investigated, according to a damning report.
Midwives given the role of supervising their peers concluded there had been no errors despite obvious evidence of serious mistakes at Furness General Hospital.
The arrangements for supervision - required by law - failed to identify poor midwifery practice at University Hospitals of Morecambe Bay NHS Foundation Trust, which runs the hospital, found the study from the Health Service Ombudsman.
There were long delays in investigating the deaths and failures by supervisory midwives to highlight obvious lapses in care - such as babies not having their heart rates monitored and not being given antibiotics despite being very poorly.
The Ombudsman, Dame Julie Mellor, has reviewed the deaths of three babies and a mother at the hospital after families complained about the care given to their loved ones.
Earlier this year, it emerged 37 families planned to take legal action against the hospital. The cases include nine baby deaths and eight cases of cerebral palsy, which can be caused by oxygen starvation at birth.
Since 2002, the legal cases have involved the deaths of 14 babies and two mothers.
Cumbria Police are investigating the death of one baby, Joshua Titcombe.
Today’s report said there is a clear “conflict of interest” among midwives working as supervisors, in that they are meant to investigate incidents relating to their peers while at the same time being responsible for their support and development.
In the case of Baby M, the report said he died following oxygen deprivation while his mother died shortly after labour.
Two supervisory midwives reviewed the records and “decided that there were no midwifery concerns that would warrant a supervisory investigation”, the report said.
But it added: “Midwife A should have identified a number of failings in the midwifery care provided for Mrs M, who was a high-risk mother because she had diabetes and was having her labour induced.
“Baby M’s heart should have been monitored at regular intervals using continuous foetal heart monitoring from the moment Mrs M arrived in the delivery suite. The fact that this wasn’t done should have prompted a decision to investigate.”
The report also criticised the local Strategic Health Authority (SHA) for failing to investigate the original decision by the supervisor of midwives not to undertake an investigation.
In the case of Baby Q, who was stillborn, it took seven months for the supervisory midwife (Midwife B) to report on what had happened.
“The supervisory investigation should have taken place in 20 days,” today’s report said. “It was seven months before it was started.
“The investigation was not independent and subsequent reports were not thorough. This meant that they did not identify that care fell short of relevant guidelines and good practice.
“Midwife B did not identify all the failings in midwifery given to Mrs Q, and she did not establish why some actions were not carried out, for example, why the midwife had not started electronic monitoring of Baby Q’s heart - it was beating faster than normal.”
The Local Supervising Authority (LSA) then failed to follow up the problems identified and “failed to carry out its functions adequately”.
A subsequent review by the SHA also took more than a year.
In the case of Baby L, his mother was given antibiotics because she was unwell but none were given to him.
He was was not seen by a paediatrician until 24 hours later and later died from pneumococcal septicaemia.
An external review was hampered because his observation chart went missing around the time he was transferred to another hospital, today’s report said.
A subsequent LSA investigation “was of poor quality, and was based on assumptions.
“When Mr L provided fresh information about Baby L’s temperature, which was accepted by the midwives, this meant that the original report was unsound.”
A further review by the SHA took six months “and did not consider the actual midwifery care provided to mother and baby.
“As a result, these six months were wasted.”
The Nursing and Midwifery Council (NMC) sets the rules and standards for LSAs.
Each LSA then appoints a practising midwife in a supervisory role.
Today’s report said there are problems in the way these midwives were supposed to be independent enough to investigate incidents while being “responsible for the professional support and development of a group of local midwives who are often their peers.
“We think this leads to an inherent conflict of interest which can put at risk the ability to identify and learn from mistakes and make midwifery services safer in future.”
The report recommended separating the roles.
Earlier this year, Health Secretary, Jeremy Hunt, ordered an investigation into what happened at Morecambe Bay. It has since emerged it will not be held in public or open to the media.
Investigation chairman, Dr Bill Kirkup, a former deputy chief medical officer at the Department of Health, said panel meetings and interviews would be held in the presence of families only due to the investigation of “sensitive and personal clinical matters”.