The investigation of serious incidents at Furness General Hospital in Barrow between 2004 and 2013 uncovered a series of failures “at every level”, from the maternity unit to those responsible for regulating and monitoring the trust which runs the unit.
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.
Dr Bill Kirkup, who chaired the Morecambe Bay investigation, said his report detailed a “distressing chain of events” which led to avoidable harm to mothers and babies.
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.
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“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.”
Dr Kirkup said the origin of the problems lay in the maternity service at Furness General and various factors “comprised a lethal mix that, we have no doubt, led to the unnecessary deaths of mothers and babies”.
The investigation found 20 instances of significant or major failures of care associated with three maternal deaths and the deaths of 16 babies at or shortly after birth.
In his report, Dr Kirkup continued: “Different clinical care in these cases would have been expected to prevent the outcome in one maternal death and the deaths of 11 babies.” He noted that this was almost four times the frequency of such failures of care at the Royal Lancaster Infirmary, the other main maternity unit run by the University Hospitals of Morecambe Bay NHS Foundation Trust.
Dr Kirkup said that signs of improvement had been shown in the maternity unit, the trust and the regulatory and supervisory systems but they were “still at an early stage and there have been previous false dawns in the trust”.
He said the events had been brought to light “thanks to the efforts of some diligent and courageous families who persistently refused to accept what they were being told”.
Last night, the English health secretary, Jeremy Hunt, described the unnecessary deaths as a “second Mid Staffs” as he apologised to the families of those who died.
Paying tribute to the “courage” of the families affected, Mr Hunt likened the problems found at the hospital to the Mid Staffs Hospital scandal, where at least 1,200 patients died because of poor care. Mr Hunt said that all 18 recommendations should be implemented right away.