The Report of the Morecambe Bay investigation
On 3 March 2015, Dr Bill Kirkup CBE published his independent investigation into the management, standard and outcomes of care delivered by maternity and neonatal services at the University Hospitals of Morecambe Bay NHS Foundation Trust between January 2004–June 2013.
The inquiry had been commissioned by Secretary of State for Health Jeremy Hunt, following considerable concern over the outcomes for mothers and babies cared for in the trust during that period.
The investigation found 20 major failures in care from 2004–13.
The Care Quality Commission (CQC) had granted foundation trust status in 2010, despite serious concerns relating to the quality of maternity services. In 2011, the Fielding report was produced internally and had identified failures in the regulatory approach at the trust. Allegedly, senior officials pushed for the report to be deleted, leading to suggestions of a 'cover-up'. Kirkup suggested that the trust's focus on achieving foundation trust status played a significant role in the poor response of the trust to the substandard care identified.
In June 2013, the CQC had published an independent report by Grant Thornton, suggesting that the CQC's oversight of the trust was poor. The report alleged CQC had provided false reassurances to Monitor and the public about the quality of care provided by the trust in 2010.
The investigation found:
- the problems at the University Hospitals of Morecambe Bay NHS Foundation Trust originated from the 'dysfunctional nature' of the maternity services at Furness General Hospital, which had included poor working relationships, deficient skills and knowledge of staff, inappropriate pursuit of 'normal childbirth', unsafe care and inadequate investigation processes
- the organisation and response of the North West Strategic Health Authority (NW SHA) and, later, the CQC was found to be poor, and the systems failed to rectify issues brought to their attention
- the Department of Health had been overly reliant on misleadingly optimistic evaluations from regulators.
The investigation made 44 recommendations for both the trust and the wider NHS. These included the suggestion to implement a national review of the provision of maternity care and paediatrics in challenging circumstances.
As a result of the investigation, Secretary of State for Health Jeremy Hunt appointed the national director of patient safety at NHS England to draft new guidelines on reporting serious incidents and asked the medical director of NHS England to review the professional codes of conduct for medical staff.
Learning not blaming
In July 2015, the government published Learning not blaming, which responded to the report on the Morecambe Bay Investigation and two other reports:
- the Freedom to speak up review by Sir Robert Francis that looked at how the NHS could create an open and honest reporting culture
- Investigating clinical incidents in the NHS, a report by the Public Administration Select Committee.
The document contained responses to each report in turn, but also identified key themes running through all three, including the importance of:
- openness, honesty and candour
- listening to patients, families and staff
- finding and facing the truth
- learning from errors and failures in care
- people and professionalism.
The Morecambe Bay Investigation report in Learning not blaming
The government's response stated that it had accepted all the recommendations made by Dr Kirkup in his report. It said that a number of these actions were already underway, including NHS England's review of maternity care, chaired by Baroness Cumberlege. This review would consider proposals for safe and efficient models of maternity care, as well as work by Health Education England to review how to best use smaller units in training programmes for staff, in order to minimise isolation.
The government outlined the need to reform the regulatory regime for midwives, since statutory supervisory functions encouraged confidentiality at the expense of improving practice and systems. Having committed in March to removing the Nursing and Midwifery Council's oversight of midwifery supervision, the government stated that it would work with the UK chief nursing officers to develop a new system. These changes were intended to ensure a separation between the regulation of midwives and the supervision of midwives.
In addition, the response stated that the secretary of state had asked Professor Sir Bruce Keogh, NHS England's Medical Director, to review the professional codes for all regulated staff in the NHS and ensure that the right incentives were in place to encourage reporting and learning from mistakes. It said that the secretary of state would review regulations, setting out statutory requirements for notifying regulators, to ensure that trust boards were required to openly report the findings of any reviews of care quality.
The Report of the Morecambe Bay Investigation.
Grant Thornton UK LLP.
The Care Quality Commission re; project Ambrose.
Grant Thornton UK LLP; 2013.
Furness baby deaths inquiry; 'Lethal mix of failures'.
BBC News; 4 February 2015.
Department of Health.
Learning not blaming: response to 3 reports on patient safety.
Department of Health; 2015.