This is another very long awaited report.
Morecombe Bay Hospital suffered a series of deaths of babies
and mothers at its maternity unit – a number far higher than this report
accepts.
There followed a similar pattern; denial by the hospital and
the professionals involved, the deaths rising to a level where local patients start
campaigning, staff move on, there is an investigation and…….everything is fine.
It isn’t.
Furness General Hospital and it’s trust has had problems in a
number of areas – for example I’ve catalogued it’s poor record in ‘Never happen
Events’.
In this case there seems t have been a climate of incompetence,
bullying and a very real cover up.
Preparing answers for everyone to follow at an inquest is the
offence of ‘perverting the course of justice; prosecutions should follow.
This report is from ‘The Independent’ newspaper today;
Morecambe
Bay hospital report finds 'lethal mix' of failures led to 11 baby deaths
The
investigation has recommended a national review of NHS maternity services
Charlie Cooper
Health
Correspondent
Tuesday 03
March 2015
A “lethal
mix” of incompetence, cover-up and failure to learn from mistakes led to the
preventable deaths of 11 babies and one mother at a rural NHS hospital in
Cumbria, a long-awaited report has said.
The inquiry
into maternity services at Furness General Hospital between 2004 and 2013 found
“failures at almost every level”, from the maternity ward to national NHS
regulators and the Department of Health, who missed opportunities to
investigate a series of serious incidents.
The
investigation, led by Dr Bill Kirkup, has recommended a national review of NHS
maternity services and care for children in rural areas.
In total
the inquiry uncovered 20 instances of significant or major care failures at
Furness General, part of the University Hospitals of Morecambe Bay (UHMB) NHS
Foundation Trust. Failures occurred in the run-up to the deaths of 16 babies at
or shortly after birth, as well as the deaths of three mothers.
Better care
could have saved the lives of 11 of the babies and one of the mothers, the report
said.
Staff on
the unit in Barrow-in-Furness lacked essential “skills and knowledge” and
working relationships between doctors and midwives were “extremely poor” with a
“them and us” mentality that prevented safe working.
Midwives
failed to keep up with the latest national standards of care and were heavily
influenced by a small group of “dominant” midwives who pursued normal
childbirth “at any cost”, the report said, leading to avoidable mortality rates
that were four times higher than neighbouring hospitals.
A “strong
group mentality” among midwives known as “the musketeers” hindered
investigations into the incidents. The inquiry found “clear evidence of
distortion of the truth” in responses to investigation. In preparation for an
inquest into one of the incidents, "model answers" to difficult
questions were circulated among midwives, the report said.
However,
the UHMB Trust, as well as regional and national authorities, were slow to
investigate and between them missed seven opportunities to intervene in the three
years from 2008, when five serious incidents occurred within a short space of
time.
Proper
investigations as far back as 2004 would have raised the alarm, the report
said.
The report
added that without the efforts of bereaved families, the scale of the failings
would never have been brought to light.
The report
makes 44 recommendations for the Trust and for the wider NHS.
Investigation
chairman Dr Bill Kirkup said: “All healthcare – everywhere – includes the
possibility of error. The great majority of NHS staff know this and work hard
to avoid it. They should not be blamed or criticised when errors occur despite
their efforts.
"But
in return, all of us who work for the NHS owe the public a duty to be open and
honest when things go wrong, most of all to those affected, and to learn from
what has happened. This is the contract that was broken in Morecambe Bay.”
He added:
“There was a disturbing catalogue of missed opportunities, initially and most
significantly by the Trust but subsequently involving the North West Strategic
Health Authority, the Care Quality Commission, Monitor, the Parliamentary and
Health Service Ombudsman and the Department of Health.”
The report
also recommended that the General Medical Council and the Nursing and Midwifery
Council should consider investigating the conduct of those involved in patient
care during the incidents investigated.
The Trust
has undergone changes in management since 2012, and the report said there were
now “welcome signs of significant recent improvement” including in maternity
services.
Neil Harris
(a don’t stop till you drop production)
Contact me: neilwithpromisestokeep@gmail.com
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