Maternity unit report coming out
An independent report which is expected to expose persistent failures at a maternity unit will be published on Tuesday.
The Morecambe Bay Investigation was launched in September 2013 following a series of deaths of newborn babies and mothers in the maternity and neonatal services unit at Furness General Hospital in Barrow, Cumbria.
Health Secretary Jeremy Hunt, who ordered the inquiry, said at the time that the principle concern was to find answers for families as to what went "desperately wrong" with care received and to ensure there was no repeat.
In January, the Sunday Times newspaper reported the investigation is expected to conclude up to 30 infants and mothers may have died due to delays in recording medical problems and poor communication at the unit run by the University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT).
Chaired by Dr Bill Kirkup, a former Department of Health associate medical director who also served on the Hillsborough Independent Panel, the investigation has focused on the management, delivery and outcomes of care between January 2004 and June 2013.
It has reviewed all deaths that occurred during that period and the response from the trust's board to such "untoward incidents".
The investigation team has also looked at how the trust reacted to a number of reports it received from 2010 onwards when it was already known there were concerns about maternity care.
An internal review in 2010 led by nursing expert Dame Pauline Fielding made wide-ranging criticisms and described team-working between key staff as "dysfunctional in some parts".
That review of maternity services - following five "serious untoward incidents" in 2008 - was not shared with the Care Quality Commission (CQC), the health regulator later said, when it gave a clean bill of health that year to the trust following its own inspection.
In October 2010 the trust was authorised foundation status by another regulator, Monitor.
The CQC went on to admit its oversight of the trust in 2010 was "poor" and apologised for providing "false assurances".
That apology came amid a damning report in June 2013 that concluded the CQC might have deliberately suppressed an internal review which highlighted weaknesses in its inspections of the trust.
In 2011, Cumbria Constabulary began investigating the 2008 death of Joshua Titcombe.
An inquest ruled he died of natural causes but that midwives had repeatedly missed chances to spot and treat a serious infection which led to Joshua's death nine days after birth.
His observation chart went missing and has never been found, while the local coroner accused midwives of "colluding" over mistakes made in Joshua's care.
The police investigation remains ongoing, although detectives ruled out taking any criminal action over a number of other deaths they investigated at Furness General's maternity unit.
Interview sessions of the Morecambe Bay Investigation were held in Preston. Although it was not a public inquiry it was open to family members.
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 NHS Federation chief executive Mike Farrar.
In a recent blog post, UHMBT's present chief executive Jackie Daniel wrote: "The Investigation's work is important in not only identifying what happened at the Trust historically and what has changed since, but also in hopefully answering the many questions the families that lost loved ones have.
"It would be inappropriate of me to second guess the contents of this important report, but we already know that the Trust has historically been responsible for failing a number of families with the most tragic of consequences.
"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."