|Furness General Hospital|
Secretary of State for Health Jeremy Hunt yesterday published the Report of the Morecambe Bay Investigation which looked into failures in care at Furness General Hospital (FGH) Maternity Unit between 2004 and 2013. You can download the report in full here. The report found:
"20 instances of failures of care at FGH that were significant or major, associated with three maternal deaths, ten stillbirths and six neonatal deaths. In 13 of these we found, in the words of the validated investigation method, 'suboptimal care in which different management would reasonably have been expected to make a difference to the outcome', including one maternal death, five stillbirths and six neonatal deaths; the prevalence of these serious failures of care was four times that at Royal Lancaster Infirmary (RLI)."
Staff wouldn't cooperate
The report found that working relationships between obstetricians, midwives and pediatricians at the hospital were extremely poor and there had been repeated failures in arranging to have the needs of at-risk patients addressed. Consultants had failed to take on the clinical responsibility of addressing these problems. None of these groups were able to work effectively together, with repeated instances of failure to communicate important clinical information about individual patients.
Managers had ignored warnings, colluded in cover-ups or professed not to have been told of any problems. Upper levels of Trust management seemed to only take an active interest in any problems where negative publicity was involved, or where it might interfere with progress towards achieving Foundation Trust status.
Failure at almost every level
The report concluded "that these events represent a major failure at almost every level. There were clinical failures, including failures of knowledge, team-working and approach to risk. There were investigatory failures, so that problems were not recognised and the same mistakes were needlessly repeated. There were failures, by both maternity unit staff and senior Trust staff, to escalate clear concerns that posed a threat to safety. There were repeated failures to be honest and open with patients, relatives and others raising concerns. The Trust was not honest and open with external bodies or the public. There was significant organisational failure on the part of the CQC, which left it unable to respond effectively to evidence of problems. The NW Strategic Health Authority (SWA) and the Public Health Services Ombudsman failed to take opportunities that could have brought the problems to light sooner, and the Department of Health was reliant on misleadingly optimistic assessments from the NW SHA. All of these organisations failed to work together effectively and to communicate effectively, and the result was mutual reassurance concerning the Trust that was based on no substance."
Families fobbed off
A campaign by bereaved families over several years to bring the problem to light was robustly resisted by the Trust. It was when the Trust applied for Foundation status in 2009 that it was required to list its current serious 'untoward incidents', and declared 12, five in FGH maternity services. This alerted Monitor, which informed the North West Strategic Health Authority (NW SHA) and the newly formed Care Quality Commission (CQC).
In 2012 the Royal Lancaster Infirmary was threatened with closure after Monitor highlighted serious failings in the A&E department as well as other inadequacies in the Trust's organisational capacity. It noted, for example, that the Trust had failed to recognise that a backlog of missed appointments was a major clinical problem affecting around 14,000 patients. (See VL report).
CQC suppressed findings
A further scandal erupted when it was revealed in 2013 that the CQC had deliberately suppressed an internal review that highlighted weaknesses in its 2010 inspection of the UHMB Trust and that the Commission had "provided false assurances to the public". It was at this point that the current investigation by the Secretary of State for Health was initiated.
While key areas of concern, such as Maternity, A&E and Stroke hospital services were targeted for improvement in 2013, the Trust was struggling with its budget, and in May 2013 circulated a consultation document (see VL report) looking at ways to shave a necessary £30 million from its £250 million annual budget to cover previous overspends - a reduction of 13%. At the same time the Trust also faced the challenge of adapting to the fundamental changes to the NHS brought about by Conservative Health Minister Andrew Lansley's new Health & Social Care Act.
Last June the Trust was again placed under special measures by Monitor following an inspection report by the Care Quality Commission (CQC) which rated the UHMB Trust 'Inadequate', mainly due to poor staffing levels resulting in inadequate and unsafe care in several areas. (See their reports)
For more information and background to the report see our previous story
Morecambe Bay Hospital Trust under Special Measures after 'Inadequate' rating.
To date, seven individuals are being investigated by the Nursing and Midwifery Council in relation to events at FGH, while eight doctors have been investigated by the GMC. One was struck off, one received a warning, and one was given advice. No action was taken against five doctors, while one further doctor was still being investigated.
Trust "Deeply sorry"
Yesterday the Trust's current chair, Jackie Daniels, issued on behalf of the Trust an unreserved apology to the families of those who suffered as a result of poor care in the maternity unit at Furness General Hospital between 2004 and 2013. You can read her full statement here.
She went on to say that:
"The Trust welcomes the publication of the Morecambe Bay Investigation report, accepts and acknowledges the criticisms and accepts its recommendations without reservation.
"Towards the end of the period covered by this report - as a consequence of the problems in maternity and neonatal services - the whole Trust board changed and the Secretary of State for Health commissioned the Morecambe Bay Investigation.
- The new board recognised the need for improvement in our maternity and neonatal services and the Trust has now made a number of service improvements including the following:
- We’ve made a significant investment in staffing with over 50 additional midwives and doctors.
- We’ve improved culture and team working at the Trust introducing, for example, multi-disciplinary ward rounds that take place four times a day on our maternity units.
- And we’ve improved patient safety by ensuring best practice and learning are shared consistently across all of our hospitals.
"The Morecambe Bay Investigation report notes that concerns over clinical practice were confined to Furness General Hospital and concludes that significant progress is being made at this maternity unit.
"We welcome these comments but we must not be complacent. We will address all the recommendations in this report to ensure that we further improve the services we offer to women and families, across our hospitals.”
Responses from our elected representatives
Conservatives and Labour both pledged to introduce after the 2010 election an independent cadre of medical examiners to check death certificates, which are usually written by junior doctors. These would also hold discussions with bereaved relatives and, where necessary, consult coroners. The long-promised system was legislated for by Labour in government in 2009 and trialled by the coalition government extensively since. However, funding arguments have contributed to delays to the reforms. Yesterday, after prompting by Shadow Health Secretary Andy Burnham (Lab), Health Secretary of State Jeremy Hunt (Con) said that they would happen.
Demonstrating his grasp of UHMBT practices, MP David Morris (Conservative, Morecambe and Lunesdale) said in parliament yesterday: "In my constituency, the effects of what has happened in our trust have been deeply felt. I would also like to reach out to my hon. Friend outside the Chamber, John Woodcock (MP Labour, Barrow in Furness). We have to put everything behind us."
Eric Ollerenshaw MP (Conservative, Lancaster and Fleetwood) said: "I assure the Secretary of State that many thousands of workers in the NHS in my area do a really good job in very difficult geographical circumstances.
"I was newly elected to Parliament in 2010. My experience, alongside that of colleagues whom I see in the House, as a constituency MP dealing with the huge institution that is the NHS has been that it is difficult to find out who is responsible, where and for what. Like everybody else, my heart goes out to the parents. I do not know how they have struggled on, with their loss and with being confronted with what almost seems like a professional or administrative closing of ranks and doors to their pleas for some information on what happened. It is just unbelievable."
Gina Dowding, Green County Councillor and member of Lancashire's Health Scrutiny Committee told VL today:
"The report makes for very sad and concerning reading. What is absolutely clear is that there was a failure to listen to patients by a whole range of organizations who should have paid attention. The whole tragedy highlights a systemic failure and underlines the need to make sure that the NHS and those who manage it are more democratically accountable; and that the the regulatory system established to ensure quality of care (that is, the governance of professional practice and standards) are transparent and sensitive to real people's experience.
"As a member of the Lancashire Health Scrutiny committee, one of the NHS scrutiny bodies that have been introduced since this tragic case, I can say that I am not confident that the systems in place today would be any better at preventing this type of tragedy occurring again."