The deaths of mothers and babies at a scandal-hit NHS hospital were not properly investigated because senior midwives “failed to identify” bad practice, according to a damning report.
Midwives entrusted with monitoring and supervising their peers at the Furness General hospital did not highlight obvious lapses in care, such as babies not having their heart rates monitored, the health service ombudsman has said in a long-awaited report.
The ombudsman, Dame Julie Mellor, has reviewed the deaths of three babies and a mother at the hospital, part of the University Hospitals of Morecambe Bay NHS Foundation Trust, after families complained about the care given to their loved ones.
Earlier this year, it emerged 37 families planned to take legal action against the hospital. The cases include nine baby deaths and eight cases of cerebral palsy.
Since 2002, the legal cases have involved the deaths of 14 babies and two mothers. Cumbria Police are investigating the death of one baby, Joshua Titcombe.
Dame Julie said the report unveiled “real weaknesses” in local supervision arrangements in midwifery. Supervising midwives had the task of investigating incidents, while also being responsible for their peers’ professional support and development. The report has called for the two roles to be separated to avoid “the potential for a conflict of interest”.
The families of babies who died said the case showed “just how dangerous the wrong type of leadership can be in the NHS”.
A statement was issued by Liza Brady and Simon Davey, whose son Alex was stillborn after midwives failed to raise concerns and involve more senior doctors; Carl Hendrickson, whose wife Nittaya and son Chester died; and James Titcombe, whose son Joshua died.
“As well as highlighting the catastrophic and repeated failures of the SHA (Strategic Health Authority), today's report also makes some substantial recommendations for changing the system of midwifery supervision in the UK,” they said.
”We have to point out, however, that it took five complaints to the SHA, a complaint to the ombudsman which was rejected, a further review by the ombudsman which again rejected the complaint and then finally the threat of judicial review and complaints from two other families before an investigation into these issues was eventually opened.”
Jackie Smith, chief executive of the professional regulator the Nursing and Midwifery Council said: “We will give full consideration to the ombudsman's recommendations and will work with colleagues across the healthcare system to ensure that the regulation of midwives reflects the needs of the four countries.”