The Morecambe Bay Investigation
Health Secretary Jeremy Hunt updates Parliament on the outcome of the independent investigation.
With your permission, Mr Speaker, I would like to make a statement on the independent investigation into the care of mothers and babies at the University Hospitals of Morecambe Bay NHS Foundation Trust, which is being published today.
I commissioned this report in September 2013 because I believed there were vital issues that needed to be addressed following serious incidents in maternity services provided by the Trust dating back to 2004.
There is no greater pain than for a parent 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 the answers to the families’ questions about what happened and why, and in doing so try to prevent a similar tragedy in the future.
We can do something else too, 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. The courage of those families in constantly reliving their sadness in a long and bitter search for the truth means that lessons will now be learned so that other families do not have to go through the same nightmare. We pay tribute to those brave families today.
I would especially like to thank Dr Bill Kirkup and his expert panel members. This will have been a particularly difficult report to research and write, but the thoroughness and fairness of their analysis will allow us to move forward with practical actions to improve safety, not just at Morecambe Bay but across the NHS.
The findings
Before we discuss the report in detail, I know the whole house will want to recognise that what we hear today is not typical of NHS maternity services as a whole, where 97% of new mothers report the highest levels of satisfaction. Our dedicated midwives, nurses, obstetricians and paediatricians work extremely long hours providing excellent care in the vast majority of cases.
Today’s report is no reflection on their dedication and commitment. But we owe it to all of them to get to the bottom of what happened so we can make sure it never happens again.
The report found 20 instances of significant or major failings of care at Furness General Hospital, associated with three maternal deaths and the deaths of 16 babies. It concludes that different clinical care would have been expected to prevent the death of 1 mother and 11 babies.
The report describes major failures at almost every level. There were mistakes by midwives and doctors, a failure to investigate and learn from those mistakes and repeated failures to be honest with patients and families - including the possible destruction of medical notes.
The report says the “dysfunctional nature of the [maternity] unit should have become obvious in early 2009 but regulatory bodies including the North West SHA, the PCTs, the CQC, Monitor and the PHSO failed to work together and missed numerous opportunities to address the issue”.
The result was not just the tragedy of lives lost. It was indescribable anguish for the families left behind. James Titcombe speaks of being haunted by “feelings of personal guilt” about his 9-day-old son who died. “If only”, he says, “I had done more to help Joshua when he still had a chance”. Carl Hendrickson, who worked at the hospital and lost his wife and baby son, told me that he was asked to work in the same unit where they’d died and even with the same equipment that had been connected to his late wife. Simon Davey and Liza Brady told me the doctor who might have saved their son Alex was shooed away by a midwife - with no one taking responsibility when he was tragically born dead.
In short it was a second Mid Staffs, where the problems, albeit on a smaller scale, occurred largely over the same time period.
In both cases perceived pressure to achieve foundation trust status led to poor care being ignored and patient safety being compromised. In both cases the regulatory system failed to address the problems quickly. In both cases families faced delay, denial and obfuscation in their search for the truth - which in this case meant at least nine significant opportunities to intervene and save lives were missed. To those who have maintained Mid Staffs was a one-off ‘local failure’, today’s report will give serious cause for reflection.
Progress to date
As a result of the new inspection regime introduced by this government, the Trust was put into special measures in June 2014. The report acknowledges improvements made since then which include more doctors and nurses, better record keeping and incident reporting, and action to stabilise and improve maternity services, including a major programme of work to reduce stillbirths.
The Trust will be re-inspected this summer when an independent decision will be made about whether to remove it from special measures. But patients who use the Trust will be encouraged that the report says the Trust “now has the capability to recover and that the regulatory framework has the capacity to ensure that it happens” and the whole house will want to support frontline staff in their commitment and dedication during this difficult period.
More broadly the report points to important improvements to the regulatory framework, particularly at the CQC which it says is now “capable of effectively carrying out its role as principal quality regulator for the first time…central to this has been the introduction of a new inspection regime under a new Chief Inspector of Hospitals”.
As a result of that regime, which is recognised as the toughest and most transparent in the world, 20 hospitals – more than 10% of all NHS acute trusts – have so far been put into special measures. Most have seen encouraging signs of progress, with documented falls in mortality rates.
Immediate actions
But there remain many areas where improvements in practice and culture are still needed.
Dr Kirkup makes 44 recommendations. 18 are for the Trust to address directly, and 26 for the wider system. The government received the report yesterday and will examine the excellent recommendations in detail before providing a full response to the house.
However there are some actions that I intend to implement immediately:
First, the NHS is still much too slow at investigating serious incidents involving severe harm or death. The Francis Inquiry was published 9 years after the first problems at Mid Staffs and today’s report is being published 11 years after the first tragedy at Furness General. The report recommends much clearer guidelines for standardised incident reporting which I am today asking Dr Mike Durkin, Director of Patient Safety at NHS England, to draw up and publish.
But I also believe the NHS could benefit from a service similar to the Airline Accident Investigation Branch of the Department of Transport. Serious medical incidents should continue to be investigated and carried out locally, but where Trusts feel they would benefit from an expert independent national team to establish facts rapidly on a no-blame basis they should be able to do so. Dr Durkin will therefore look at the possibility of setting up such a service for the NHS;
Secondly, whilst we have made good progress in encouraging a culture of openness and transparency in the NHS, this report makes clear there is a long way to go. It seems medical notes were destroyed and mistakes covered up at Morecambe Bay, quite possibly because of a defensive culture where the individuals involved thought they would lose their jobs if they were discovered to have been responsible for a death.
But within sensible professional boundaries, no one should lose their job for an honest mistake made with the best of intentions. The only cardinal offence is not to report that mistake openly so that the correct lessons can be learned.
The recent recommendations from Sir Robert Francis on creating an open and honest reporting culture in the NHS will begin to improve this. But I have today asked Professor Sir Bruce Keogh, Medical Director of NHS England, to review the professional codes of both doctors and nurses and to ensure that the right incentives are in place to prevent people covering up instead of reporting and learning from mistakes. Sir Bruce led the seminal Keogh Inquiry into hospitals with high death rates two years ago that led to a lasting improvement in hospital safety standards and has long championed openness and transparency in healthcare. For this vital work he will lead a team which will include the Professional Standards Authority, the GMC, NMC and HEE, and will report back to the Health Secretary later this year.
The report also exposed systemic issues about the quality of midwifery supervision. Whilst the investigation was underway, the King’s Fund conducted a review of midwifery regulation for the NMC which recommended that effective local supervision needs to be carried out by individuals wholly independent from the Trust they are supervising. The government will work closely with stakeholders to agree a more effective oversight arrangement and will legislate accordingly. I have asked for proposals on the new system by the end of July this year.
For too long the NMC had the wrong culture and was too slow to take action - but I am encouraged that they have recently made improvements. They have today apologised to the families affected by the events at Morecambe Bay. The NMC is already investigating the fitness to practice of seven midwives who worked at the Trust during this time, and they will now forensically go through any further evidence gathered by the Investigation to ensure that any wrongdoing or malpractice is investigated. Anyone who is found to have practised unsafely or who covered up mistakes will be held to account, which for the most serious offences includes being struck off. The NMC also has the power to pass information to the police if they feel a criminal offence may have been committed and they will not hesitate to do so if their investigations find evidence which warrants this.
The government remains committed to legislation for further reform of the NMC at the earliest opportunity.
The report expresses a ‘degree of disquiet’ over the initial decision of the Parliamentary and Health Service Ombudsman not to investigate the death of Joshua Titcombe. I know the Public Administration Select Committee is already considering these issues and will want to reflect carefully on the report as it considers any improvements that can be made as part of its current inquiry.
Finally, I expect the Trust to implement all 18 of the recommendations that have been assigned to them in the report. I have asked Monitor to ensure this happens within the designated timescales, as I want to give maximum reassurance to the patients and families who are using the hospital that no time is being wasted in learning necessary lessons.
Culture change in the NHS
To conclude, Mr Speaker, we should recognise that despite many challenges, NHS staff have made excellent progress recently in improving the quality of care - with the highest ever ratings from the public for safety and compassionate care.
The tragedy we hear about today must strengthen our resolve to deliver real and lasting culture change so these mistakes are never repeated. That is the most important commitment we can make to the memory of the 19 mothers and babies who lost their lives at Morecambe Bay, including those named in today’s report - Elleanor Bennett, Joshua Titcombe, Alex Brady-Davey, Nittaya Hendrickson and Chester Hendrickson.
This statement is their legacy, and I commend it to the house.