NHS failed families of babies who died at Furness hospital inquiry says
Dame Julie Mellor found blunders by staff were not looked into properly and that the local NHS did not pursue the truth enough.
The NHS failed the families of three babies who died at a scandal-hit hospital by not properly investigating mistakes by midwives, the health service ombudsman says on Wednesday in a scathing indictment of the actions of staff at the time and after.
The inquiry by Dame Julie Mellor, which also examined the death of the mother of one of the trio, found that blunders by staff were not looked into properly and that the local arm of the NHS did not pursue the truth vigorously enough.
Mellor’s findings cover the deaths of three boys, Joshua Titcombe, Alex Davey-Brady and Chester Hendrickson, and that of Chester’s mother Nittaya, between July and October 2008 at Furness general hospital in Cumbria.
The report, published on Wednesday, is highly critical of arrangements whereby certain midwives were meant to supervise the work of colleagues. Those local supervisors of midwives failed to uncover or raise the alarm about the poor care involved in these three cases, Mellor said.
Chester died in July 2008 after being deprived of oxygen while his mother died soon after. Although two supervisory midwives reviewed the records of what had happened they “decided that there were no midwifery concerns that should warrant a supervisory investigation”, Mellor’s report said.
Midwife A “should have identified a number of failings in the midwifery care provided to Mrs M [Nittaya Hendrickson], who was a high-risk mother because she had diabetes and was having her labour induced.”
In addition, Chester’s heart “should have been monitored at regular intervals using continuous foetal heart monitoring from the moment Mrs M arrived in the delivery suite”, though that was not done and no investigation launched later.
The hospital’s investigation into Alex Davey-Brady’s stillbirth in September 2008 should have occurred within 20 days. Instead, Mellor found, “it was seven months before it was started [and] the investigation was not independent and subsequent reports were not thorough”.
A midwife referred to as midwife B “did not identify all the failings in midwifery care given to [Alex’s mother] [and] did not establish why some actions were not carried out, for example, why the midwife had not started electronic monitoring of [Alex’s] heart when it was beating faster than normal.”
In the case of Joshua Titcombe, whose death in October 2008 from pneumococcal septicaemia after not seeing a paediatrician for 24 hours is being investigated by Cumbria police, again the local supervisory authority of midwives failed to discharge its duties properly.
It did not hold an adequate investigation and did not begin that until the hospital trust’s inquiry had finished, which meant events were no longer fresh in the minds of key staff involved, found Mellor.
When Joshua’s father provided new information about his son’s temperature, which showed that the original report into his death was “unsound”, the local midwifery officer did not pass that to the Nursing and Midwifery Council, which regulates midwives.
The ombudsman’s separate reports into the three cases also criticises the NHS’s then strategic health authority covering the north-west of England, which at the time was headed by Mike Farrar, one of the service’s most senior leaders, who stepped down as chief executive of the NHS Confederation in September.
Mellor demanded urgent reform of the system of supervising midwives because supervisors face an obvious “conflict of interest” in monitoring the performance of colleagues while simultaneously being responsible for their support and development.
The families involved welcomed Mellor’s reviews of the deaths but said they had had to repeatedly request that proper investigations were carried out.
Gill Harris, NHS England’s nursing director in the north of England, said: “It is important that mistakes like this don’t happen to again. We would like to express our deepest apologies for the distress caused to the families affected.
“Many of the improvements recommended have already been implemented and we are committed to continue working openly and effectively to improve working practices to ensure safety within our maternity services both regionally and nationally.”
Farrar said: “I remain deeply saddened about the original failings in care at Morecambe Bay Hospital and I apologise unreservedly for the fact that the strategic health authority team was unable to deal with the complaints in the manner families deserved.”