The Report of the Morecambe Bay Investigation

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.

2 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. 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.

3 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.

4 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. 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.

5 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.

6 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. 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.

7 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.

8 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. 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.

9 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.

10 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.