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Hunt apology over baby unit deaths

Health Secretary Jeremy Hunt has described the unnecessary deaths of 11 babies and one mother at a maternity unit as a "second Mid Staffs" as he apologised to the families of those who died.

Today's report into serious incidents at Furness General Hospital in Barrow, Cumbria, 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.

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.

He told MPs: "In short, it was a second mid-Staffs, where the problems, albeit on a smaller scale, occurred largely over the same time period."

Addressing the Commons, Mr Hunt said: "There is no greater pain for a parent than to lose a child and to do so knowing it was because of mistakes that we now know were covered up makes the agony even worse.

"Nothing we say or do today can take away that pain. But we can at least provide answers to the families' questions about what happened and why and in doing so try to prevent a similar tragedy in the future."

He added that something else could be done, "which should have happened much earlier. And that is on behalf of the Government and the NHS to apologise to every family that has suffered as a result of these terrible failures".

Mr Hunt said that in both Morecambe Bay and Mid Staffs, perceived pressure to achieve foundation trust status led to poor care being ignored and patient safety being compromised, and in both cases the regulatory system failed to address the problems quickly.

Families in both cases faced delays and denials in their search for their truth, he added.

"To those who have maintained Mid Staffs was a one-off local failure, today's report will give serious cause for reflection."

The independent report found there was a "lethal mix" of problems at the "seriously dysfunctional" maternity unit, including 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.

"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 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.

Mr Hunt said that all 18 recommendations made directly concerning the trust should be implemented right away.

A further 26 relating to the wider system were also made, which he said he would be examining, but he added that clearer guidelines for reporting serious incidents should be drawn up immediately.

Dr Kirkup said signs of improvement had already 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".

"This emphasises the importance of understanding the extent and depth of the changes necessary," he said.

"Second, there is a clear sense that neither the Trust nor the wider NHS has yet formally accepted the degree to which things went wrong in the past and admitted it to affected families. Until this happens, there is little prospect of those families accepting that progress can be made."

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".

Dr Kirkup said: "Those families deserve great credit. That it needed their efforts over such a prolonged period reflects little credit on any of the NHS organisations concerned.

"Today, the name of Morecambe Bay has been added to a roll of dishonoured NHS names that stretches from Ely Hospital to Mid Staffordshire.

"This report sets out why that is and how it could have have avoided. It is vital that the lessons, now plain to see, are learned and acted upon, not least by other trusts which must not believe 'that it could not happen here'.

"If those lessons are not acted upon, we are destined sooner or later to add again to the roll of names."

The trust's present chief executive, Jackie Daniel, was asked at a press conference - staged by the trust - whether a cover-up had effectively taken place.

Ms Daniel said: "I think the report makes Bill Kirkup's views on this very very clear and we support those views. I think it is very difficult in full light of the facts not to conclude that the trust was less than honest and some of the staff were less than honest in terms of some of those issues.

"It is very difficult to come to a different conclusion."

She added the report was "the definitive picture" of what happened between 2004 and 2013 and said the trust accepted and acknowledge the criticism made including that of poor working relationships which she said led to "a venomous culture".

A completely new board was in place which recognised the need for improvement in maternity and neonatal services, she said.

"However we are not complacent about how much more there is to do," she said.

She continued: "I would like to add my own apology. During the period covered by this investigation there were some very serious failings. The trust then failed to shown openness and transparency in acknowledging those failing so on behalf of all the staff at the trust I want to say sorry to all of those who have suffered, and I promise along with the chairman and the board we will do everything we can to improve maternity and neonatal services in the future."

The trust's medical director David Walker said that seven midwives had been subjected to trust disciplinary processes, of which two were dismissed, three received written warnings and two received verbal warnings.

The midwives had been referred to the Nursing and Midwivery Council (NMC).

Five doctors also faced disciplinary hearings by the trust, with two of those receiving verbal warnings. One has since retired and another has resigned, although the doctor who has quit will be subject to a fitness to practise hearing.

The trust said it would have a "thorough look" at the investigation report and would hold others to account if need be.

Dr Kirkup said earlier that a copy of the report would be passed to Cumbria Constabulary, while the trust said it had worked closely with the police and would continue to do so as the report was analysed.


From Belfast Telegraph