Probe uncovers midwifery failings
An investigation into the deaths of three babies and a mother at a scandal-hit hospital has uncovered serious failings in midwifery care and follow-ups into what happened.
Joshua Titcombe, Alex Davey-Brady and Nittaya and Chester Hendrickson all died following mistakes at F urness General Hospital.
A report from the Health Service Ombudsman found midwives given the role of supervising their peers concluded there had been no errors despite obvious evidence of mistakes.
The arrangements for supervision - required by law - failed to identify poor midwifery practice at University Hospitals of Morecambe Bay NHS Foundation Trust, which runs the hospital.
Ombudsman Dame Julie Mellor reviewed the deaths of the three baby boys and Mrs Hendrickson after their families complained about the care given.
Today, the families welcomed the report but said it had taken numerous complaints and requests before an investigation was carried out.
The report said there is a clear "conflict of interest" among midwives working as supervisors - they are meant to investigate incidents relating to their peers while at the same time being responsible for their support and development. Dame Julie called for these roles to be separated.
In the case of baby Chester, the report said he died following oxygen deprivation while his mother died shortly after labour.
Two supervisory midwives reviewed the records and "decided that there were no midwifery concerns that would warrant a supervisory investigation", the report said.
But it added: "Midwife A should have identified a number of failings in the midwifery care provided for Mrs M (Mrs Hendrickson), who was a high-risk mother because she had diabetes and was having her labour induced.
"Baby M's heart should have been monitored at regular intervals using continuous foetal heart monitoring from the moment Mrs M arrived in the delivery suite. The fact that this wasn't done should have prompted a decision to investigate."
The report also criticised the local Strategic Health Authority (SHA) for failing to investigate the original decision by the supervisor of midwives not to undertake an investigation.
In the case of Alex Davey-Brady - who was stillborn and referred to as Baby Q in today's report - it took seven months for the supervisory midwife (Midwife B) to report on what had happened.
"The supervisory investigation should have taken place in 20 days," the report said. "It was seven months before it was started.
"The investigation was not independent and subsequent reports were not thorough. This meant that they did not identify that care fell short of relevant guidelines and good practice.
"Midwife B did not identify all the failings in midwifery given to Mrs Q, and she did not establish why some actions were not carried out. For example, why the midwife had not started electronic monitoring of Baby Q's heart - it was beating faster than normal."
The Local Supervising Authority (LSA) then failed to follow up the problems identified and "failed to carry out its functions adequately".
A subsequent review by the SHA also took more than a year.
In the case of Joshua Titcombe, whose case is being investigated by Cumbria Police, his mother was given antibiotics because she was unwell but none were given to him.
He was was not seen by a paediatrician until 24 hours later and he went on to die from pneumococcal septicaemia.
The report said the hospital trust had estimated he would have had a 90% chance of survival if given antibiotics earlier.
An external review was hampered because his observation chart went missing around the time he was transferred to another hospital, the report said.
A subsequent LSA investigation "was of poor quality, and was based on assumptions.
"When Mr L provided fresh information about Baby L's (Joshua's) temperature, which was accepted by the midwives, this meant that the original report was unsound."
A further review by the SHA took six months "and did not consider the actual midwifery care provided to mother and baby.
"As a result, these six months were wasted."
Earlier this year, it emerged 37 families planned to take legal action against the hospital. The cases include nine baby deaths and eight cases of cerebral palsy, which can be caused by oxygen starvation at birth.
Since 2002, the legal cases have involved the deaths of 14 babies and two mothers.
The Nursing and Midwifery Council (NMC) sets the rules and standards for LSAs. Each LSA then appoints a practising midwife in a supervisory role.
Dame Julie said: "We think that there are real weaknesses in the statutory arrangements for the local supervision of midwives which risk failure to learn from mistakes.
"This cannot be in the interests of mothers and babies, or of midwives, and must change.
"'We questioned why the supervision and regulatory arrangements were not the same for midwives as they are for the main medical professions, hence our recommendation that the roles of supervision and professional regulation are separated to avoid the potential for a conflict of interest.
"In all three of our cases, the local regulatory midwifery supervision and investigations at local level failed to identify poor midwifery practice. Our report highlighted that the confidential nature of supervision can prevent information about poor care from being escalated effectively into hospital clinical governance or the regulatory system."
Mike Farrar said: "As one of the former chief executives of what was the North West Strategic Health Authority (SHA), I fully accept the decision of the Ombudsman.
"I remain deeply saddened about the original failings in care at Morecambe Bay hospital and I apologise unreservedly for the fact that the SHA team was unable to deal with the complaints in the manner the families deserved.
"I would also fully endorse the recommendations that the Ombudsman has made about the regulation and supervision of midwifery."
Gill Harris, NHS England's nursing director in the North, said: "We will consider the proposals carefully. It is important that mistakes like this don't happen again. We would like to express our deepest apologies for the distress caused to the families affected."
NMC chief executive, Jackie Smith, said: "We will give full consideration to the Ombudsman's recommendations and will work with colleagues across the healthcare system to ensure that the regulation of midwives reflects the needs of the four countries. "
Royal College of Midwives' chief executive Cathy Warwick said it recognised the importance of keeping its regulatory framework under review to ensure public protection but added : "We must be extremely careful not to lose sight of the benefits of midwifery supervision."
Earlier this year, Health Secretary Jeremy Hunt, ordered an investigation into what happened at Morecambe Bay. It has since emerged it will not be held in public or open to the media.
Investigation chairman, Dr Bill Kirkup, a former deputy chief medical officer at the Department of Health, said panel meetings and interviews would be held in the presence of families only due to the investigation of "sensitive and personal clinical matters".