The Morecambe Bay Investigation, into maternal and baby deaths, reported its findings yesterday (03/03/2015).
This Investigation was established by the Secretary of State for Health in September 2013 following concerns over serious incidents in the maternity department at Furness General Hospital (FGH), part of the University Hospitals of Morecambe Bay (UHMB) NHS Foundation Trust.
Chaired by Dr Bill Kirkup, the investigation reviewed cases from 2004 - 2013.
The report details 20 instances of significant failures of care in the FGH maternity unit which may have contributed to the deaths of 3 mothers and 16 babies. Different clinical care in these cases would have been expected to prevent the death of 1 mother and 11 babies.
Systemic failures were found on all levels, from the maternity unit to the Trust's management to heath regulators.
The report also makes 44 recommendations for the Trust and wider NHS, aimed at ensuring the failings are properly recognised and acted upon.
Sands Chief Executive, Neal Long, has responded to the findings.
“Sands welcomes this significant and wide-reaching report. We extend our thoughts to the many families whose lives have been devastated by events at Morecambe Bay NHS Foundation Trust and who have worked so tirelessly, for so many years, to seek the truth. Some have waited more than a decade for clear and honest answers. And it is a matter of shame that it has been down to them to bring this litany of failures to light.
“The failures described in Dr Kirkup’s report are not just those of the Trust but also of the agencies tasked with monitoring the safety of health care in England. The failings and their consequences have devastated families and put the lives of mothers and babies at continued risk.
“We particularly welcome Dr Kirkup’s recommendation that clear standards for open and honest incident reporting need to be developed. Sands has long called for all baby deaths to be rigorously and objectively investigated so that lessons from poor care, where it exists, can be learnt and mistakes not repeated in the future. To be effective, this process has to be open and honest and should always include the parents’ perspective of events. Parents are important historians of their own care and Morecambe Bay NHS Foundation Trust clearly failed to take their views seriously.
“Thousands of families are bereaved every year when their baby dies before or within days of birth and many parents experience such tragedies without ever truly understanding what contributed to the death of their baby. This important investigation has identified key recommendations relevant to all maternity services throughout the UK that must be implemented if tragic deaths such as these are to be avoided in the future.”
You can read the report here.