Advising with empathy and experience

"Lethal mix" of failings led to deaths.

A “lethal mix” of failings at almost every level led to the unnecessary deaths of one mother and 11 babies in the maternity unit of a Cumbrian hospital, an independent report says.

The investigation into deaths at Furness General Hospital, Barrow, between 2004 and 2013 found maternity services were beset by a culture of denial, collusion and incompetence.

Work at the unit was found to be “seriously dysfunctional” with poor clinical competence, extremely poor working relationships, and a determination among midwives to pursue normal childbirth “at any cost”.

The Furness General Hospital midwives were so cavalier they became known as “The Musketeers”.

The Morecambe Bay investigation was set up by health secretary, Jeremy Hunt, in 2013 to investigate concerns over what appeared to be several unnecessary deaths within what became University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT).

Under the investigation, a panel of experts examined events at Furness General from 1 January 2004 to 30 June 2013. The report’s author, Dr Blll Kirkup, said: “Our findings 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.”

He said frontline staff were responsible for “inappropriate and unsafe care” and response to potentially-fatal incidents by the trust hierarchy was “grossly deficient, with repeated failure to investigate properly and learn lessons.”

Dr Kirkup said this “lethal mix” of factors had led to 20 instances of significant or major failures of care at Furness General Hospital, associated with three maternal deaths and the deaths of 16 babies at, or shortly after, birth.

He said: “Different clinical care in these cases would have been expected to prevent the outcome in one maternal death and the deaths of 11 babies.”

The report says that warning signs should have been spotted in 2004, when a baby died from the effects of shortage of oxygen due to a mismanaged labour. An investigation into the death was both “rudimentary”, “over-protective of staff” and failed to identify underlying problems.

Between 2006 and 2008 there were further missed opportunities including five serious incidents between 2006 and 2007. Each was investigated so inadequately that the underlying problems went unnoticed.

In 2008, there was a cluster of five serious incidents in the unit. These included a baby who died due to the effects of a shortage of oxygen in labour, a mother who died following untreated high blood pressure, and a mother and baby who died from an amniotic fluid embolism. A baby was damaged due to a shortage of oxygen during labour, while another died from an unrecognised infection.

Dr Kirkup added: “All showed evidence of the same problems of poor clinical competence, insufficient recognition of risk, inappropriate pursuit of normal childbirth and failures of team-working. Initial investigation was again deficient and failed to identify manifest problems.”

An external investigation was commissioned following a complaint about another incident that was felt “likely to generate adverse publicity.”

Dr Kirkup said the reaction of staff in the maternity unit was shaped both by a denial that there was a problem and “a strong group mentality amongst midwives characterised as ‘The Musketeers’.

“We found clear evidence of distortion of the truth in responses to investigation, including, particularly, the supposed universal lack of knowledge of the significance of hypothermia in a newborn baby.”

He added that the disappearance of certain records was of concern to the panel of experts. The investigators found evidence of “inappropriate distortion” in the preparation for an inquest, with the circulation of “what we could only describe as model answers.”

The report makes no criticism of staff for individual errors, but condemned incidents of collusion as both “inexcusable” and “unprofessional.”

It adds: “The failure to present a complete picture of how the maternity unit was operating was a missed opportunity that delayed both recognition and resolution of the problems and put further women and babies at risk.”

The trust’s managers allowed themselves to be distracted by their pursuit of foundation status.

When healthcare regulator Monitor suspended the trust’s application for foundation status in 2009 it looked to the Care Quality Commission (CQC) “as the arbiter of clinical quality, including patient safety” and highlighted a series of failed communications between the CQC and the office of the health service ombudsman (PHSO).

Crucially, this was at a point in 2009 when the PHSO was considering a complaint from James Titcombe, the father of Joshua, who died in 2008 as a result of an infection missed for almost 24 hours.

Officials at both the PHSO and the CQC – which has previously been accused of a cover up over Morecambe Bay – as well as from the local NHS, were among more than 100 people interviewed.

Kirkup said: “Our conclusion is that these events represent a major failure at almost every level. There were repeated failures to be honest and open with patients, relatives and others raising concerns. The trust was not honest and open with external bodies or the public.”

The chair of the trust’s board, Pearse Butler, said: “This trust made some very serious mistakes in how it cared for mothers and their babies and the same mistakes were repeated. And after those mistakes, there was a lack of openness  in acknowledging to families what had happened.

“On behalf of the trust, I apologise unreservedly to the families concerned. I’m deeply sorry that so many people have suffered as a result of these mistakes.”

The trust added that the entire composition of its board had changed near the end of the period covered by the report and it recognised the need for improvement in its maternity and neonatal service. It also said it now had 50 more midwives and doctors, and had also improved its culture and team-working.