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Baby deaths inquiry: NHS criticism expected Furness baby deaths inquiry: 'Lethal mix of failures'
(about 3 hours later)
Failures at a maternity unit where a number of newborn babies and mothers died are expected to be exposed later. A "lethal mix" of failures at a Cumbrian hospital led to the unnecessary deaths of 11 babies and one mother, an inquiry has ruled.
The investigation into Morecambe Bay NHS Foundation Trust focused on the care given at Furness General Hospital in Cumbria between 2004 and 2013. The investigation into Morecambe Bay NHS Foundation Trust found 20 major failures in care from 2004 to 2013 at Furness General Hospital.
The independent inquiry was ordered by Health Secretary Jeremy Hunt 18 months ago following several damning reports. It called the avoidable incidents "serious and shocking".
It also came after it emerged a number of families were taking legal action over the care provided. And it criticised the wider NHS for the way it had monitored and regulated events at the hospital.
The investigation has been led by Dr Bill Kirkup, a former senior Department of Health official who has previously led an inquiry into Jimmy Savile's behaviour at Broadmoor Hospital. In an echo of the inquiries in the Stafford Hospital scandal, the report said the problems found represented a "simultaneous failure of a great many systems at almost every level, from labour ward to the headquarters of national bodies".
As well as criticising the hospital, he is also expected to focus on the role of regulators. The investigation - led by Dr Bill Kirkup, a former senior Department of Health official - found:
The problems began coming to light five years ago with reports that there were serious problems at the hospital's maternity unit. Despite the failures starting in 2004 and continuing throughout the period, including a cluster of five major incidents in 2008, it was only in 2011 that the issues at Furness General came to wider attention.
Police were called in after an inquest in June 2011 into the death of newborn Joshua Titcombe, of Dalton, Cumbria. This was after strong criticism from a coroner who looked into the death of newborn Joshua Titcombe. The coroner ruled Joshua had died of natural causes in 2008 but midwives had repeatedly missed opportunities to spot and treat a serious infection.
It ruled Joshua had died of natural causes in 2008 but midwives had repeatedly missed opportunities to spot and treat a serious infection. Around this time, a report came to light that the trust itself had commissioned. It was produced in early 2010 but "suppressed" by the trust.
The trust itself commissioned an internal report, which was produced in early 2010 by nursing expert Dame Pauline Fielding. But before that, the trust had failed to act on earlier incidents and even distorted the way information was presented to inquests.
It said the hospital's maternity services were "dysfunctional" and was critical of the relationships between doctors, midwives and managers. Catalogue of errors
But the trust was accused of suppressing these findings, as the report was not published until a year later. The CQC, regional health authority and ombudsman had not acted properly on what they knew either. There was knowledge of five major incidents in 2009 as the trust had revealed them as part of its application for foundation trust status, which is reserved for elite trusts.
But the regulators did not take the necessary action to fully investigate what had happened, and the trust gained foundation status in September 2010.
Dr Kirkup said: "This was a disturbing catalogue of missed opportunities."
His inquiry makes 44 recommendations, including:
Six midwives are already due before the NMC later this year - and a seventh is being investigated.
Meanwhile, a police investigation into the death of Joshua Titcombe is continuing, and the Health and Safety Executive is looking into the case.
Health Secretary Jeremy Hunt is due to make a statement later.
The parents' storyThe parents' story
Parent power prompted midwife reviewParent power prompted midwife review
James Titcombe's son Joshua was nine days old when he died of sepsis. He was born at Furness General Hospital and was transferred to two other hospitals before dying in Newcastle.James Titcombe's son Joshua was nine days old when he died of sepsis. He was born at Furness General Hospital and was transferred to two other hospitals before dying in Newcastle.
"We asked repeatedly if Joshua should have antibiotics and we were told 'No, he didn't [need any]'," said Mr Titcombe."We asked repeatedly if Joshua should have antibiotics and we were told 'No, he didn't [need any]'," said Mr Titcombe.
"He was wheezing, and he wasn't feeding properly, and my wife called the emergency bell because he was grunting."He was wheezing, and he wasn't feeding properly, and my wife called the emergency bell because he was grunting.
"And every time, we were told Joshua was fine and that there was nothing to worry about. At no stage was a doctor ever called.""And every time, we were told Joshua was fine and that there was nothing to worry about. At no stage was a doctor ever called."
Afterwards Joshua's progress chart went missing, never to re-emerge, and the coroner later said there was a suspicion that it may have been deliberately destroyed.Afterwards Joshua's progress chart went missing, never to re-emerge, and the coroner later said there was a suspicion that it may have been deliberately destroyed.
The Care Quality Commission has also been criticised for its oversight of the trust. Its inspectors concluded the maternity unit was up to standard in 2010 and a year later it awarded the trust foundation status, reserved for elite hospitals.
A review by Grant Thornton consultants in 2013 suggested the CQC may well have "deliberately covered-up" what it knew about its failings in regulating the hospital - an internal report had been carried out in 2011 but was not published.
The regional health authority and Parliamentary and Health Service Ombudsman have also been criticised for not taking action earlier.
More than 100 people have been interviewed by investigators during the inquiry, including families who have been cared for, staff at the hospital and senior officials in the health service.
Mr Hunt has said the reaction to the problems at Morecambe were "completely unacceptable" and the events a "personal tragedy" for the families involved.