1 The Report of the Morecambe Bay Investigation Dr Bill Kirkup CBE. March 2015. The Report of the Morecambe Bay Investigation An independent Investigation into the management, delivery and outcomes of care provided by the maternity and neonatal services at the University Hospitals of Morecambe Bay NHS. Foundation Trust from January 2004 to June 2013. Dr Bill Kirkup CBE. March 2015. Morecambe Bay Investigation copyright 2015. The text of this document (this excludes, where present, the Royal Arms and all departmental or agency logos) may be reproduced free of charge in any format or medium provided that it is reproduced accurately and not in a misleading context. The material must be acknowledged as Morecambe Bay Investigation copyright and the document title specified. Where third party material has been identified, permission from the respective copyright holder must be sought. Any enquiries related to this publication should be sent to us at This publication is available at ISBN 9780108561306.
2 ID 26021502 03/15 47487 19585. Printed on paper containing 75% recycled fibre content minimum This edition printed in the UK by the Williams Lea Group and published by The Stationery Office Contents Introduction 5. Executive Summary 7. Chapter One: Investigation Findings 13. Dysfunctional maternity unit 13. Delayed problem recognition 15. Response following 2008 events 16. University Hospitals of Morecambe Bay NHS Foundation Trust response 19. Subsequent investigations 21. The role of external bodies 27. Chapter Two: Background 39. Note on abbreviations 39. Background to the Investigation 39. Establishing the Investigation 40. Selection and appointment of a Panel of expert advisors 41. Communication with the families 42. Methodology and analysis of the evidence 43. The Investigation 's evidence-gathering process 45. Communications 47. The Investigation timeline 48. Chapter Three: Clinical services 49. Background 49. Review of clinical practice in maternity and neonatal services, University Hospitals of Morecambe Bay NHS Foundation Trust 51.
3 Maternity unit response to serious untoward incidents and complaints 57. Recent changes and developments 64. Chapter conclusions 66. Chapter Four: Trust response 69. Background 69. Clinical governance and complaints 69. Trust profile, 2004 08 77. Trust profile, 2008 10 79. Following Foundation Trust authorisation, 2010 12 91. Whistleblowing response 101. Chapter conclusions 102. 3. The Report of the Morecambe Bay Investigation Chapter Five: External response 105. Introduction 105. Context 106. Primary Care Trusts 107. The North West Strategic Health Authority 112. The Care Quality Commission 131. Monitor 143. The Department of Health 149. Secretary of State for Health and Ministerial team 153. Parliamentary and Health Service Ombudsman 155. The Nursing and Midwifery Council 160. The General Medical Council 162. The Health and Safety Executive 164. Relationships between organisations and coordination of responsibilities 167. Chapter conclusions 170. Chapter Six: Q. uestions raised about the scrutiny of perinatal and maternal deaths 173.
4 Inquests into deaths of babies affected by perinatal events 173. Scrutiny of perinatal and maternal deaths 174. Chapter Seven: Assessment of current position 177. The Trust's ability to discharge its duties in delivering maternity services 177. The Trust's governance and ability to function as an effective organisation 178. Capacity and capability of regulators and others 181. Chapter Eight: Conclusions and recommendations 183. Conclusions 183. Recommendations 185. Appendix 1: List of abbreviations 193. Appendix 2: Acknowledgements 195. Appendix 3: Ministerial statement 197. Appendix 4: The Investigation 's panel of expert advisors 199. Appendix 5: M. orecambe Bay Investigation Schedule of Panel meeting dates and venues 201. Appendix 6: Membership of the Investigation Panel's sub-groups 203. Appendix 7: Invitation to families 205. Appendix 8: Interview protocol 207. Appendix 9: List of interviewees 213. Appendix 10: L. etter from Dr William Moyes, former Executive Chair of Monitor, to the Investigation Chairman, Dr Bill Kirkup CBE 219.
5 4. Introduction For the great majority, pregnancy and childbirth should be a positive and happy experience that culminates in a healthy mother and baby. This means, however, that on those occasions when things do go wrong, the effects are even more devastating than in other areas of healthcare. Maternity care must reconcile these dual aspects in order to be safe, effective and responsive. When it does not, the consequences may be stark. This Report details a distressing chain of events that began with serious failures of clinical care in the maternity unit at Furness General Hospital, part of what became the University Hospitals of Morecambe Bay NHS Foundation Trust. The result was avoidable harm to mothers and babies, including tragic and unnecessary deaths. 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.
6 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. This Report includes detailed and damning criticisms of the maternity unit, the Trust and the regulatory and supervisory system. In view of the progress that is now undoubtedly being made in all these areas, the necessity for this Investigation to lay bare all of this may perhaps be questioned, both by Trust staff (who undoubtedly feel beleaguered) and by others. There are two reasons to resist this view. First, although the signs of improvement are welcome, they are still at an early stage and there have been previous false dawns in the Trust; this emphasises the importance of understanding fully the extent and depth of the changes necessary. 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.
7 These events have finally been brought to light thanks to the efforts of some diligent and courageous families, who persistently refused to accept what they were being told. 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 been avoided. It is vital that the lessons, now plain to see, are learnt 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. BILL KIRKUP CBE. March 2015. 5. Executive summary 1. The Morecambe Bay Investigation was established by the Secretary of State for Health to examine concerns raised by the occurrence of serious incidents in maternity services provided by what became the University Hospitals of Morecambe Bay NHS Foundation Trust (the Trust), including the deaths of mothers and babies.
8 Relatives of those harmed, and others, have expressed concern over the incidents themselves and why they happened, and over the responses to them by the Trust and by the wider National Health Service (NHS), including regulatory and other bodies. 2. We have carried out a thorough and independent Investigation of these events, covering the period from 1 January 2004 to 30 June 2013. The Investigation Panel included expert advisors in midwifery, obstetrics, paediatrics, nursing, management, governance and ethics. We reviewed 15,280 documents from 22 organisations, and we interviewed 118 individuals between May 2014. and February 2015. Family members of those harmed were invited to attend interviews and Panel meetings as observers. 3. 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, and it is important for the lessons of these events to be learnt and acted upon, not only to improve the safety of maternity services, but also to reduce risk elsewhere in NHS.
9 Systems. 4. The origin of the problems we describe lay in the seriously dysfunctional nature of the maternity service at Furness General Hospital (FGH). Clinical competence was substandard, with deficient skills and knowledge; working relationships were extremely poor, particularly between different staff groups, such as obstetricians, paediatricians and midwives; there was a growing move amongst midwives to pursue normal childbirth at any cost'; there were failures of risk assessment and care planning that resulted in inappropriate and unsafe care; and the response to adverse incidents was grossly deficient, with repeated failure to investigate properly and learn lessons. 5. Together, these factors comprised a lethal mix that, we have no doubt, led to the unnecessary deaths of mothers and babies. We reviewed cases, including all the maternal deaths and deaths of babies in the period under Investigation , using a validated method, and found 20 instances of significant or major failures of care at FGH, associated with three maternal deaths and the deaths of 16 babies at or shortly after birth.
10 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. 6. These problems did not develop overnight, and the first sign of their presence occurred in 2004, when a baby died from the effects of shortage of oxygen, due to a mismanaged labour. Serious incidents happen in every health system because of the nature of healthcare, and no blame should be attached to staff who make mistakes. It is, however, vital that incidents are properly investigated, in order to identify problems and prevent a recurrence. The Investigation in 2004 was rudimentary, over-protective of staff and failed to identify underlying problems. 7. The Report of the Morecambe Bay Investigation 7. Between 2004 and the end of 2008, there was a series of further missed opportunities to identify problems in the unit. Between 2006 and 2007, five more serious incidents occurred that showed evidence of problems similar in nature to the 2004 incident; investigations followed the same inadequate process and failed to identify problems.