3 Mar 2015

Pattern of failures that put babies’ lives at risk

One mother and 11 babies would not have died if they had received better care at Furness General Hospital.

That is the stark finding of today’s report into Morecambe Bay trust, and what happened on Furness maternity unit between 2004 and 2013.

The investigation, led by Dr Bill Kirkup, pulls no punches. From the very first page it says there was a “catalogue of failures at almost every level – from the maternity unit to those responsible for regulating and monitoring the Trust”.

And there were at least nine significant missed opportunities to intervene.

The report lays blame across a sweeping array of organisations, but first and foremost it is placed at the door of  the maternity unit itself where “clinical competence was substandard”, with deficient skills and knowledge.

“Working relationships were extremely poor, particularly between different staff groups,much as obstetricians, paediatricians and midwives,” the report adds.

There was a growing move to pursue normal childbirth “at any cost”, the report says.  It adds there was a denial on the unit of any problem and a strong group mentality amongst midwives characterised as the “musketeers”.

The inquiry found clear evidence of a distortion of the truth among the midwives in response to investigations, the disappearance of records and a distortion in the preparation for inquests with the circulation of “model answers”.


Rhiannon Davies with her baby girl, Kate, 1 March 2009. Kate died hours after her birth at the Ludlow maternity unit

The report found 20 instances of significant or major failures of care at the hospital.

These are linked to the deaths of three mothers and 16 babies at or shortly after birth.  Different care, the report says, may have saved the lives of one of those mothers and 11 of those babies.

The report divides the dates from 2004 to 2008 and from 2008 to 2013, not least because after 2008 came what can only be described as a cluster of five serious incidents.

This included the birth and, tragically, the death of Joshua Titcombe.

He was born in the unit in October 2008 but only lived for nine days. An inquest later heard that midwives and medical staff made 10 serious errors that contributed to his death from blood poisoning.

But where his father James Titcombe and his mother Hoa at first thought they were alone – soon it became clear to them there were other families.

Finding the pattern

And this is what lies at the heart of this report.  The failure to link up all the incidents so it took years for the pattern to become clear.

The first identified death was in 2004.  A baby starved of oxygen.

“Serious incidents happen in every health system,” the report says.  But it is vital they are investigated.

“The investigation in 2004 was rudimentary, over-protective of staff and failed to identify underlying problems,” the report adds.

In 2008, however, there was a baby who died from a shortage of oxygen at birth, a mother who died from untreated high blood pressure, a mother and baby who died from an amniotic fluid embolism, a baby who died from a shortage of oxygen – and Joshua, who died from an unrecognised infection.

The trust, the report says, did recognise that all was not well on the unit.  One letter from a consultant obstetrician setting out concerns over one of the incidents was sent to the clinical director and medical director “but failed to prompt any documented reaction”.

Another complaint made to the trust board was investigated, and although the investigation was flawed it did “unequivocally identify systemic failings for the first time”, the report says.

The failings went far beyond Furness, however.   There were failings at almost every level, the report adds.

Organisational failure

There were clinical failures, failures by maternity staff and senior trust staff to escalate concerns; there were repeated failures to be open and honest with patients, relatives and others raising concerns.

The trust was not honest and open with external bodies or the public, the report says.

There was significant organisational failure on the part of the Care Quality Commission (CQC), which left it unable to effectively respond to evidence of problems, the report found.

And it says the North West Strategic Health Authority and the Parliamentary Health Service Ombudsman failed to take opportunities that could have brought the problems to light sooner.

In addition, the Department of Health was “reliant on misleadingly optimistic assessments” from the health authority.

It is a report in this respect just like that of Mid-Staffordshire, where so many patients died, too.

As this report concludes: “All of these organisations failed to work together effectively and to communicate effectively, and the result was mutual reassurance concerning the trust that was based on no substance.”

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