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Morecambe Bay hospital report finds 'lethal mix' of failures led to 11 baby deaths Report prompts NHS to launch a review into maternity care across England
(about 7 hours later)
A “lethal mix” of incompetence, cover-up and failure to learn from mistakes led to the preventable deaths of 11 babies and one mother at a rural NHS hospital in Cumbria, a long-awaited report has said. The NHS is to launch a review of maternity services in England in the wake of a damning report that said a “lethal mix” of incompetence and cover-up led to the preventable deaths of 11 babies and one mother at a rural hospital in Cumbria.
The inquiry into maternity services at Furness General Hospital between 2004 and 2013 found “failures at almost every level”, from the maternity ward to national NHS regulators and the Department of Health, who missed opportunities to investigate a series of serious incidents. Midwives colluded to protect one another from blame for a series of incidents at Furness General Hospital and even referred to themselves as “the musketeers” because of their “one for all” approach, an inquiry said.
The investigation, led by Dr Bill Kirkup, has recommended a national review of NHS maternity services and care for children in rural areas. The investigation uncovered “failures at almost every level”, from the maternity ward to national and regional NHS regulators and the Department of Health, which between them missed several opportunities to investigate concerns about the unit.
In total the inquiry uncovered 20 instances of significant or major care failures at Furness General, part of the University Hospitals of Morecambe Bay (UHMB) NHS Foundation Trust. Failures occurred in the run-up to the deaths of 16 babies at or shortly after birth, as well as the deaths of three mothers. Examining cases between 2004 and 2013, the inquiry uncovered 20 instances of significant or major care failures at Furness General, part of the University Hospitals of Morecambe Bay (UHMB) NHS Foundation Trust.
Better care could have saved the lives of 11 of the babies and one of the mothers, the report said. Failures occurred in the run-up to the deaths of 16 babies and three mothers. Better care could have saved the lives of 11 of the babies and one mother, the report said.
Staff on the unit in Barrow-in-Furness lacked essential “skills and knowledge” and working relationships between doctors and midwives were “extremely poor” with a “them and us” mentality that prevented safe working. Despite serious incidents as early as 2004, and a series of five separate events in 2008, it was not until 2011 that standards of care on the unit gained wider attention – largely thanks to the efforts of the families of patients.
Midwives failed to keep up with the latest national standards of care and were heavily influenced by a small group of “dominant” midwives who pursued normal childbirth “at any cost”, the report said, leading to avoidable mortality rates that were four times higher than neighbouring hospitals. The Health Secretary, Jeremy Hunt, said the care failings, along with the failure to be open and honest about mistakes, amounted to “a second Mid Staffs”. NHS England chief executive Simon Stevens said the report was “truly shocking”.
A “strong group mentality” among midwives known as “the musketeers” hindered investigations into the incidents. The inquiry found “clear evidence of distortion of the truth” in responses to investigation. In preparation for an inquest into one of the incidents, "model answers" to difficult questions were circulated among midwives, the report said. The Health Secretary, Jeremy Hunt (Susannah Ireland) The report documents how staff on the unit in Barrow-in-Furness lacked essential “skills and knowledge”. Working relationships between doctors and midwives were “extremely poor” with a “them and us” mentality. Midwives failed to keep up with the latest standards of care and were heavily influenced by a small group of “dominant” midwives who pursued an “overzealous” policy of normal childbirth “at any cost”, the report said, leading to avoidable mortality rates that were four times higher than at a neighbouring hospital.
However, the UHMB Trust, as well as regional and national authorities, were slow to investigate and between them missed seven opportunities to intervene in the three years from 2008, when five serious incidents occurred within a short space of time. Faced with an external investigation in 2008, midwives developed a “one for all” approach. An email from former maternity risk manager Jeanette Parkinson even referred to the midwifery team as “the musketeers”. In preparation for an inquest into one of the incidents, she also circulated “model answers” to difficult questions among her colleagues, the report said. Key clinical records went missing and the inquiry panel could not rule out the possibility this had been deliberate.
Proper investigations as far back as 2004 would have raised the alarm, the report said. However, the Trust – as well as regional and national authorities – were slow to investigate and between them missed a number of opportunities to intervene in the three years from 2008.
The report added that without the efforts of bereaved families, the scale of the failings would never have been brought to light.
The report makes 44 recommendations for the Trust and for the wider NHS.
Investigation chairman Dr Bill Kirkup said: “All healthcare – everywhere – includes the possibility of error. The great majority of NHS staff know this and work hard to avoid it. They should not be blamed or criticised when errors occur despite their efforts.
"But in return, all of us who work for the NHS owe the public a duty to be open and honest when things go wrong, most of all to those affected, and to learn from what has happened. This is the contract that was broken in Morecambe Bay.”
He added: “There was a disturbing catalogue of missed opportunities, initially and most significantly by the Trust but subsequently involving the North West Strategic Health Authority, the Care Quality Commission, Monitor, the Parliamentary and Health Service Ombudsman and the Department of Health.”
The report also recommended that the General Medical Council and the Nursing and Midwifery Council should consider investigating the conduct of those involved in patient care during the incidents investigated.
The Trust has undergone changes in management since 2012, and the report said there were now “welcome signs of significant recent improvement” including in maternity services.
Seven midwives have been referred to the Nursing and Midwifery Council and two have been dismissed, the Trust said. The Trust has undergone changes in management since 2012, and the report said there were now “welcome signs of significant recent improvement” including in maternity services.Seven midwives have been referred to the Nursing and Midwifery Council and two have been dismissed, the Trust said. The Trust has undergone changes in management since 2012, and the report said there were now “welcome signs of significant recent improvement” including in maternity services.
Pearse Butler, chair of the Trust board, apologised to the families, admitting it had made “very serious mistakes in the way it cared for mothers and their babies”.Pearse Butler, chair of the Trust board, apologised to the families, admitting it had made “very serious mistakes in the way it cared for mothers and their babies”.
“More than that, the same mistakes were repeated. And after making those mistakes, there was a lack of openness from the Trust in acknowledging to families what had happened. This report vindicates these families.”“More than that, the same mistakes were repeated. And after making those mistakes, there was a lack of openness from the Trust in acknowledging to families what had happened. This report vindicates these families.”
*The competence of staff fell “significantly below the standard required for a safe effective service”. Essential knowledge was lacking, guidelines not followed and warning signs in pregnancy not recognised or acted upon.
*The unit was described as “isolated both geographically and professionally” and was unsupported by the local healthcare system.
*The Trust failed to make a link between the five incidents in 2008 and an internal review of maternity care in 2010 was subject to “an element of conscious suppression”. At the time the trust was seeking to achieve foundation trust status.
*The North West Strategic Health Authority “accepted assurances there were no systemic problems” at the trust.
*Six of the avoidable deaths at the trust took place after 2008 and after several “missed opportunities” to investigate.
Rachael Pells
James Titcombe’s son Joshua died nine days after he was born at Furness General Hospital in November 2008. He was transferred to two other hospitals before he died in Newcastle. Mr Titcombe and his wife, Hoa, argued for an inquest to take place.James Titcombe’s son Joshua died nine days after he was born at Furness General Hospital in November 2008. He was transferred to two other hospitals before he died in Newcastle. Mr Titcombe and his wife, Hoa, argued for an inquest to take place.
After the birth, Joshua was said to be wheezing and not feeding properly. Medical staff repeatedly assured the family that he was fine and no doctor was called. Joshua later died from a serious infection. His progress chart also went missing and was never found, leading to suspicion that it may have been deliberately destroyed.After the birth, Joshua was said to be wheezing and not feeding properly. Medical staff repeatedly assured the family that he was fine and no doctor was called. Joshua later died from a serious infection. His progress chart also went missing and was never found, leading to suspicion that it may have been deliberately destroyed.
In 2011 it was confirmed that midwives had repeatedly missed chances to spot and treat the sepsis which led to Joshua’s death.In 2011 it was confirmed that midwives had repeatedly missed chances to spot and treat the sepsis which led to Joshua’s death.
Following the publication of the report yesterday, Mr Titcombe said it had “vindicated” families like his who have held the hospital to account. Following the publication of the report yesterday,  Mr Titcombe said it had  “vindicated” families like  his who have held the hospital to account.
“We talk about ‘missed opportunities’ in this report. That, for me, means not having a six-year-old boy,” he said. “This report gives Joshua and other babies and mothers who died a legacy. That’s got a huge amount of meaning.“We talk about ‘missed opportunities’ in this report. That, for me, means not having a six-year-old boy,” he said. “This report gives Joshua and other babies and mothers who died a legacy. That’s got a huge amount of meaning.
“You can’t turn back the clock but at least we can say we’ve done everything we could.” “You can’t turn back the clock but at least we can  say we’ve done everything  we could.”
Speaking about the fact that midwives at Furness General Hospital are still being investigated over the case six years later, Mr Titcombe said: “How could this have happened? Notes going missing, this concealment of reports, the lack of regard for safety – how can that have happened and yet it’s not criminal?”Speaking about the fact that midwives at Furness General Hospital are still being investigated over the case six years later, Mr Titcombe said: “How could this have happened? Notes going missing, this concealment of reports, the lack of regard for safety – how can that have happened and yet it’s not criminal?”
Rachael Pells Nittaya Hendrickson and her newborn son Chester died at Furness General Hospital in Barrow, Cumbria in 2008. Ms Hendrickson, who was diabetic, was admitted to the hospital on 31 July 2008 and had her labour induced.
  A few minutes after her waters broke, she had a fit. Doctors were called but she had a second fit and died soon after. An inquest ruled that Ms Hendrickson died of natural causes. Doctors later confirmed that Chester had suffered severe brain damage due to lack of oxygen during the birth. His father, Carl Hendrickson, was forced to make the decision not to continue Chester’s treatment.
  Further investigation into the deaths found that Ms Hendrickson was not cared for properly and that her child’s heartbeat was not monitored properly.
Mr Hendrickson said in 2011 that he felt “vindicated” that a police investigation had been launched into the maternity unit. Ms Hendrickson, who was originally from Thailand, also left behind a son called Conrad.
Mr Hendrickson, from Ulverston, Cumbria, said at the time of the inquest: “Our family has been absolutely devastated by the death of Nittaya and Chester.”