A “lethal mix” of problems at a “seriously dysfunctional” maternity unit led to the unnecessary deaths of 11 babies and one mother, an independent inquiry has found.
The investigation of serious incidents at Furness General Hospital in Barrow, Cumbria, between 2004 and 2013 uncovered a series of failures “at every level” from the maternity unit to those responsible for regulating and monitoring the trust which runs the unit.
Different clinical care in these cases would have been expected to prevent the outcome in one maternal death and the deaths of 11 babiesDr Bill Kirkup, who chaired the Morecambe Bay investigation
Among the “shocking” problems found were substandard clinical competence, extremely poor working relationships between different staff groups and repeated failure to investigate adverse incidents properly and learn lessons.
Dr Bill Kirkup, who chaired the Morecambe Bay investigation, said his report detailed a “distressing chain of events” which led to avoidable harm to mothers and babies.
He said: “What followed was a pattern of failure to recognise the nature and severity of the problem with, in some cases, denial that any problem existed, and a series of missed opportunities to intervene that involved almost every level of the NHS.
“Had any of those opportunities been taken, the sequence of failures of care and unnecessary deaths could have been broken. As it is, they were still occurring after 2012, eight years after the initial warning event, and over four years after the dysfunctional nature of the unit should have become obvious.”
Dr Kirkup said the origin of the problems lay in the maternity service at Furness General and various factors “comprised a lethal mix that, we have no doubt, led to the unnecessary deaths of mothers and babies”.
The investigation found 20 instances of significant or major failures of care associated with three maternal deaths and the deaths of 16 babies at or shortly after birth.
In his report, Dr Kirkup continued: “Different clinical care in these cases would have been expected to prevent the outcome in one maternal death and the deaths of 11 babies.”
He noted that was almost four times the frequency of such failures of care at the Royal Lancaster Infirmary, the other main maternity unit run by the University Hospitals of Morecambe Bay NHS Foundation Trust.
Looking ahead, he said that signs of improvement had been shown in the maternity unit, the trust and the regulatory and supervisory systems but they were “still at an early stage and there have been previous false dawns in the Trust”.
“This emphasises the importance of understanding the extent and depth of the changes necessary,” he said.
“Second, there is a clear sense that neither the Trust nor the wider NHS has yet formally accepted the degree to which things went wrong in the past and admitted it to affected families. Until this happens, there is little prospect of those families accepting that progress can be made.”
He 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”.
Dr Kirkup said: “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.”