Ex-NHS boss Farrar avoids Morecambe Bay question
Former NHS Confederation Chief Executive Mike Farrar is confronted by Channel 4 News over a “dysfunctional” maternity unit, which led to the unnecessary deaths of 11 babies and one mother.
A report into the University Hospitals of Morecambe Bay NHS Foundation outlined a “lethal mix” of problems at Furness General Hospital in Barrow, Cumbria, between 2004 and 2013.
Among the “shocking” problems found were substandard clinical competence, extremely poor working relationships between different staff groups and repeated failure to investigate adverse incidents properly and learn lessons.
Read Victoria Macdonald's blog: 'A baby died an avoidable death' - one family's fight for justice
More than 100 NHS bosses and midwives were interviewed including Tony Halsall, the trust chief executive between 2007 and 2012, and Cynthia Bower, the CQC chief executive from 2009 to 2012.
Others questioned were former NHS chief executive David Nicholson, Dame Pauline Fielding and former NHS Confederation Chief Executive Mike Farrar.
Mr Farrar was previously the chief executive of the North West England Strategic Health Authority from 2006 to 2011, at the time the scandals at UHMBT took place.
Following the report published on Tuesday, Mr Farrar avoided questions over the failings.
‘Dysfunctional’
Dr Bill Kirkup, who chaired the Morecambe Bay investigation, said his report detailed a “distressing chain of events” which led to avoidable to harm to mothers and babies.
Read Victoria Macdonald's blog: Pattern of failures that put babies' lives at risk
He said: “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.
The sequence of failures of care and unnecessary deaths could have been broken. Dr Bill Kirkup
“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.”
‘Vindication’
In a statement, UHMBT said it had apologised unreservedly to the families involved.
Pearse Butler, the chair of the trust board, said: “This trust made some 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.
This trust made some very serious mistakes in the way it cared for mothers and their babies. Pearse Butler
“For these reasons, 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. As the chair of the trust board, it’s my duty to ensure that lessons are learned and that we do everything we possibly can to make sure nothing like this happens again.”
Read more: Cynthia Bower - I'm deeply sorry for child deaths
The trust said that towards the end of the period covered by the report the whole trust board changed, with the new board recognising the need for improvement in its maternity and neonatal service.
Health Secretary Jeremy Hunt also apologised on behalf of the government to and NHS to all the families who suffered as a result of the failings, saying that he hoped for a “lasting culture change”:
#Kirkup finally gets to truth thanks 2 @JamesTitcombe @LizaJ_Brady @HendricksonCarl: they faced unimaginable pain &showed remarkable courage
— Jeremy Hunt (@Jeremy_Hunt) March 3, 2015
#kirkup uncovers 2nd Mid Staffs in same period: poor care ignored, families faced delay & denial, big failures in inspection and oversight.
— Jeremy Hunt (@Jeremy_Hunt) March 3, 2015
Pleased #kirkup found new Chief Inspector regime means CQC fit 2 spot poor care ‘for first time’.M.Bay legacy must be lasting culture change
— Jeremy Hunt (@Jeremy_Hunt) March 3, 2015
Following the announcement, NHS England announced a national review into maternity services, including making recommendations on efficient models of maternity services.
Simon Stevens, chief executive of NHS England, said: “Most mums say they get great NHS maternity care, but equally we know we can do better in many places, and today’s Morecambe Bay report is truly shocking. So the time is right to take stock, and consider how we can best deliver maternity care safely in every part of the country, while better meeting the high expectations women and their families rightly have.”
