Morecambe Bay Trust inquiry: Hospital to face criticism for deaths at maternity unit

Mothers and babies at Morecambe Bay put at risk by poor communication, says report

Health Secretary Jeremy Hunt, who ordered the inquiry, said at the time that the principal concern was to find answers for families as to what went “desperately wrong” with care received and to ensure no repeat (Susannah Ireland/The Independent)

Persistent failures at a maternity unit where up to 30 newborn babies and mothers may have died due to delays in recording medical problems and poor communication are expected to be exposed by an independent report published tomorrow.

It is thought the Morecambe Bay investigation will find that mothers and babies were put at risk because midwives and doctors at Furness General Hospital in Barrow, Cumbria were at loggerheads and that crucial medical notes exposing sub-standard treatment have since been lost or destroyed.

All deaths that occurred between January 2004 and June 2013 at the hospital’s maternity and neo-natal services unit have been examined by investigators who interviewed more than 100 NHS bosses and midwives.

Although it was not a public inquiry, it was open to relatives of victims.

The response to such “untoward incidents” from the University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT) which runs the unit has also been scrutinised by the investigation, chaired by Dr Bill Kirkup, a former Department of Health associate medical director who also served on the Hillsborough Independent Panel.

Health Secretary Jeremy Hunt, who ordered the inquiry, said at the time that the principal concern was to find answers for families as to what went “desperately wrong” with care received and to ensure no repeat.

But Carl Hendrickson, whose wife and newborn son died after being admitted to the unit, said he was “apprehensive that this report will come out and we won’t actually see any action from it.

“There has to be accountability, not only to the staff who made mistakes but also to the managers who allowed this to happen,” added Mr Hendrickson, whose wife Nittaya, 35, had a heart attack after suffering a rare amniotic fluid blood clot while giving birth to Chester. The baby died the following day.

The report which was originally due by summer 2014 is also likely to look at how the trust reacted to a number of reviews it received from 2010 onwards, when it was already known there were concerns about maternity care.

Following five “serious untoward incidents” wide-ranging criticisms were made that year in an internal review led by nursing expert Dame Pauline Fielding, who described team-working between key staff as “dysfunctional in some parts”.

But health regulator, the Care Quality Commission (CQC), said that the review was not shared with them and following its own inspection they gave the trust a clean bill of health.

CQC later admitted its oversight of the trust in 2010 was “poor” and apologised for providing “false assurances” following a damning 2013 report that concluded it might have deliberately suppressed an internal review which highlighted weaknesses in its inspections of the trust.

A police investigation into the 2008 death of Joshua Titcombe also remains ongoing, although Cumbria Police ruled out taking any criminal action over a number of other deaths they investigated at Furness General’s maternity unit.

An inquest ruled that Joshua died of natural causes but that midwives had repeatedly missed chances to spot and treat a serious infection which led to his death nine days after birth, while the coroner accused midwives of “colluding” over mistakes made in Joshua’s care. His observation chart has never been found.

The trust will not comment until the report is published, but in a recent blog post the current chief executive Jackie Daniel wrote: “It is our responsibility to ensure we never let his happen again and we must use the investigation’s report to help us fully understand what happened and learn any lessons that need to be learned for the benefit of everyone who uses our hospitals.”