Maternity care at the University Hospitals of Morecambe Bay Trust has been heavily critcised by the Care Quality Commission in a new inspector report which criticises the care across the trust’s three hospitals and raises concerns over the trust’s culture and leadership.
The trust has now been effectively put into special measures by NHS England and has had conditions imposed by the CQC which is demanding urgent improvements.
Maternity care at the trust’s Furness General Hospital was heavily criticised by an inquiry in 2015, led by Dr Bill Kirkup, which labelled the unit “dysfunctional” and described a “lethal mix” of failings by the trust and wider NHS which directly led to the avoidable deaths of 11 babies and one mother.
Since then, Morecambe Bay has been a by-word for maternity failure and the Kirkup inquiry triggered a suite of national initiatives to try and improve the care of mothers and babies in the NHS.
James Titcombe, whose son Joshua died as a result of mistakes at the trust in 2008, told The Independent he was shocked by the CQC’s findings and felt “deeply let down”. He said it was clear the trust had “lost its memory” after the tragic events that led to the Kirkup report.
The findings also raise questions over how trusts can maintain improvements in the longer term.
Ted Baker, CQC’s chief inspector of hospitals, told The Independent the deterioration at Morecambe Bay was “disappointing”, adding: “It is critical that trusts have high quality clinical leadership, an open positive culture and effective governance. Unless these are all addressed improvements will not be sustained. Achieving this in services under pressure is a challenge for any leader, which is why the trust is being given more intensive external support.”
In its latest inspection report published today, the CQC said there were pockets of poor culture throughout the trust which had remained for a long time.
It said there was a lack of staff on the maternity units with women who were assessed as being at risk of sepsis not receiving appropriate care. Poor records meant it was not clear if deterioration in patients was being recognised and the inspectors said staff did not assess the risk of women in labour and escalating those concerns.
The Kirkup inquiry highlighted similar failings with midwives not intervening or raising concerns with some staff pursuing an agenda to promote ‘normal births’ “at all costs”.
The CQC said the trust board “lacked curiosity”, adding: “There was a general theme of accepting reassurance given, rather than seeking assurance.”
The regulator also criticised a report the trust had commissioned to score its progress against the 18 recommendations in the Kirkup report which concluded 15 had been achieved and three were partially achieved.
But the watchdog said: “CQC reviewed the draft report but were not assured that it was a robust review. The review was completed virtually with no onsite activity to observe day to day practice or culture.
“Our findings from the inspection did not provide assurance about the governance and oversight of risks or the long-term sustainability of the maternity services provided.”
Mr Titcombe, who led a campaign to expose the poor care at the trust after the death of his son, said: “After the Kirkup report the trust promised it would learn and become an exemplar organisation. I do believe they did make real improvements under the previous head of midwifery but this just goes to show how quickly things can slip backwards if you don’t have the right leadership.
“It is an organisation that has lost its memory and that is really sad for all the families who were involved in what happened before.”
He said he was encouraged that the concerns had been exposed by the CQC and not as a result of poor care and deaths adding: “The trust isn’t being defensive about this which is positive.”
He said the virtual review of maternity services appeared to be nothing more than a “tick box exercise”.
The CQC inspectors visited the trust in April and May and also looked at medical care, emergency wards, stroke care and surgery.
The overall rating of the trust has been left at “requires improvement” with its leadership rated inadequate. The regulator has imposed conditions on the Royal Lancaster Infirmary over concerns about delays in the care of stroke patients.
In its report the CQC concluded the “range and nature” of the issues it found meant there were “significant and ongoing challenges in the capacity of the organisation to deliver and make sustained improvements at pace.”
Ann Ford, CQC’s deputy chief inspector of hospitals in the north, said: “This recent inspection makes disappointing reading. We found a significant downturn in the quality of services provided by the trust, and patients were not receiving the standard of care they deserve.
“The improvements which were demonstrated at previous inspections of Furness General Hospital’s maternity department have not been sustained and the service has deteriorated, affecting patients and staff.
“However, this does not detract from the excellent work carried out by staff within the trust who, on the whole are providing care, treating patients with compassion sometimes under difficult circumstances.
"While we understand that the leadership team is trying to resolve the issues, it’s clear to us the trust is unable to do so without support.”
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