James Watts, consultant in anaesthesia and critical care, looks at the important lessons to be learned following recent events that occurred at Morecambe Bay Trust Obstetric Unit
The recently published Professional Standrads Authority (PSA) report into the events that occurred at Morecambe Bay Trust Obstetric Unit at Furness General Hospital (FGH), Barrow-in -Furness  is one of several reports to examine this issue over the last few years, and has finally given a coherent account as to how departmental, trust, regional and national Clinical Governance systems failed, allowing a dysfunctional unit to carry on providing services without review or effective challenge. The most infamous failing which occurred there relates to the events surrounding the tragic death of Joshua Titcombe, also known as Baby A.  However, the failings were much broader and fundamental in nature than simple clinical error, and should have been robustly addressed earlier. As such, there are important lessons to be learned by all clinicians, including anaesthetists.
Furness General Hospital (FGH)
FGH is a geographically isolated hospital, managed by University Hospitals of Morecambe Bay NHS Foundation Trust (‘the Trust’). It provides many services including a 24-hour A&E, Obstetric services, Surgery, and oncology.
The obstetric unit performs approximately 1,200 deliveries per annum, one of the lowest figures of any general hospital in North West England [3,4]. Like many smaller hospitals, serving disparate and isolated communities, there have been local resistance and political influences that have resisted its closure or downgrading during various mergers. At the time these events occurred, the Trust was subjected to a number of external stressors, including CQC visits and an application for Foundation status.
The Obstetric Unit
Isolated and intermittent concerns had been raised about the Obstetric Unit for some time, but began to gain some traction after the unexpected death of baby D in 2004, following the poor management and monitoring of labour. In 2005, both Mrs E and her baby died after complications of an improperly monitored antenatal period. Then, in 2008, there was an unprecedented run of untoward incidents resulting in the deaths of Joshua Titcombe, baby F, Baby G and Mrs B and her baby. The latter was attributed to complications of an amniotic fluid embolus.
The department was known to be dysfunctional. A cadre of Midwifes, known locally as “the Musketeers”, were avid proponents of natural child birth, to the degree that they would not inform medical staff of possible complications. This resulted in “silo working” so that there was poor, or no, engagement or challenge from the obstetricians and other midwifery colleagues. There was also noted to be poor working relationships between the Obstetric and paediatric department, and the Midwives and neonatology.
Serious untoward incidents were investigated by the risk manager, known widely as Midwife 7. She held a number of roles, including being a trainer, and the staff representative for disciplinary matters. Retrospectively, it was concluded that this represented a serious conflict of interest, in that it was not only her role to make recommendations arising from serious untoward incidences (SUI), but also to implement and monitor them. Her reports varied between inaccurate and protectionist. For example, in the case of Joshua Titcombe, it was claimed that early signs of sepsis in the neonate were not core midwifery knowledge. The reports were generally taken at face value by Trust management, and used as evidence that “all was well” although there remained some misgivings. Later reviews by the NMC and CQC found that there was an emphasis on protecting the practice of staff rather than protecting mothers and babies. This masked poor competency, and poor implementation of knowledge and skills.
The Fielding report 
Trust management commissioned a report from Dame Pauline Fielding to look at issues arising from the five SUIs that occurred in 2008, which were at that time regarded as “unconnected”. She was asked not look at the events themselves because lessons appeared to have been learnt and implemented and some inquests had been concluded. The report stated
“The apparent “cluster‟ of these episodes appeared to the review team to have been coincidental rather than evidence of serious dysfunction. That said, the need to improve several aspects of the maternity service, already acknowledged in external and internal investigations, should be seen as a positive opportunity for constructive developments.”
The report also stated:
“The hospital facilities are not entirely fit for purpose, particularly with respect to the labour ward environment and the distance of theatres, and compare unfavourably with others in the trust. …. There is a stable cadre of experienced nursing and midwifery staff but, perhaps because of the unit’s geographical location which places it in the most remote and inaccessible corner of the trust’s catchment area, the trust has found it increasingly difficult to attract and appoint high calibre staff of all types. …It was clear from most of our interviews that team working is dysfunctional in some parts of the maternity service. Whilst this is apparent in all professional groups, it is particularly evident in relation to medical staff. The consultant obstetricians in the trust did not present as a cohesive group with common aims, agreed approaches to the provision of services and productive ways of working together. They were preoccupied with their own agendas and reported little confidence in the clinical leadership…There is also a history of poor relationships between midwives and neonatal staff although this was felt to be improving….”
It has been denied that the report was buried. It was however, not widely circulated, and was not declared to either the Trust Board, the CQC or Monitor for some considerable time. The recommendations were not noted, and not implemented in any clinical governance initiative, as it was felt that the lessons learn from these matters were already being implemented.
Inquests into the 2008 deaths occurred in 2008 and 2009. The coroner was not critical of events relating to the deaths, relying on the clinical evidence, particularly the reports written by midwife 7. What the coroner was unaware of was an email circulated between the midwives that had contained “model answers”. This email was entitled “NMC shit”. Mr James Titcombe (Father of Joshua Titcombe) became aware of the email later when he was told he had been subject of a data breach, the email having been sent to a different department in the Trust. He was made fully aware of the actual contents later, and then complained that this was evidence of the midwives colluding in a cover up. The second inquest into Joshua’s death in 2011 agreed with him.
Several complaints were made to the police about the deaths, including allegations of deliberate cover up. After several years, the police concluded that there was no proof of actual criminal activity. However, as unrest persisted the police forwarded their information to the Nursing and Midwifery Council (NMC) at various points over the years.
The NMC has been very heavily criticised in the PSA report, although the report has made it clear that improvements have been, and are continuing, to be made.
Unlike the GMC, the NMC did not have an internal fitness to practise investigation department. If a complaint against a registrant was to be pursued, it was delegated to one of a number of specialist solicitors, who would take clinical advice if necessary. Complaints were not linked, and it is acknowledged that the NMC audit trail was so poor that evidence was lost for considerable periods of time. In some cases, issues were accidentally closed, and then for legal reasons could not be opened. When the complaint about collusion, evidenced by the “NMC Shit” email were raised, the investigation concentrated on the use of swear words in the title of the email rather than the possible collusion. There is also some evidence that Mr Titcombe was perceived as a troublemaker rather than a complainant. It is also clear that communication with complainants was poor, some not knowing that their complaints had been dealt with until some considerable time after the file had been closed. NMC procedures were halted for long periods of time, due to ongoing police investigations and inquests, leading to some cases being open for years without resolution. In the end, disciplinary action concluded in 2017. Midwife 7 and several of her colleagues were erased from the register due to serious professional misconduct.
The Kirkup report 
Kirkup was asked by the Secretary of State for Health to investigate the root causes of the poor clinical performance, and why it had gone undetected for so long . The report found failures in local, regional and national governance, with failures of oversight and intervention at almost every level, compounded by a culture of denial. The Trust failed to deal with the issues partly due to a lack of understanding, and partly because management was distracted by its application to become a Foundation Trust.
External body supervision
Several processes were running at the same time that the clinical issues were being raised. These included application for Foundation Status, CQC visits and interest from the SHA.
While these individual processes and the organisations responsible for them, raised concerns, an over-reliance on reassurance from the trust, based as it was on the flawed reports written by Midwife 7, led to each organisation seemingly endorsing the Trust for good practice. It is clear on reviewing these actions that each organisation fed off the “good review” from its cousins. For example, a change of management at the CQC led to significant concerns being downgraded on the expectation that the Trust would take robust action, allowing the Foundation Status application to proceed unimpaired. The fact that the Foundation process proceeded unimpaired was taken as quality assurance of clinical services. In the meantime, the “light touch” supervision from the SHA accepted the reassurances given by the trust. The department of Health was also aware of the concerns, but relied on the reassurances from the NW SHA, and the endorsements from the CQC and Monitor, without further scrutiny.
The concerns were then obscured for a couple of years, until they surfaced again by other means.
This is a very quick summary of the events that occurred between 2004 and 2017. And does not include mention of the other investigations and reviews that were occurring, such as those related to the performance of the neonatology unit, reports from the Ombudsman which added to the slowly growing evidence of a serious problem that was not being addressed.
The root cause of these failings and their tragic outcomes is the dysfunctional nature of the department, where aberrant working practices went unchallenged and a small number of practitioners went to great length to propound their own prejudices and conceal their poor competency and outcomes. Although these problems were widely suspected and should have been robustly dealt with, the higher Trust management was distracted and fully occupied with the processes it needed to complete in the headlong rush to Foundation status. The bodies that should have been overseeing the trust and ensuring that it met appropriate standards relied overly on the reassurances and reports without properly scrutinising or considering the growing concerns.
There are therefore a lot of lessons that individuals and organisations can learn from these tragic events
- Poor cooperation and lack of respect in multidisciplinary teams can lead to Silo working, which causes serious dysfunction. This is a risk to patient safety that all team members need to address and which needs to be urgently tackled by clinical leadership
- Criminal investigation mechanisms may not be an appropriate way in which to investigate clinical issues, and can actually delay the detection and resolution of professional performance issues
- Bodies which oversee Trust performance should be less willing to take explanations of concerns at face value and have a more robust approach to addressing concerns
- Regulatory bodies need to react more swiftly to serious concerns, make investigatory processes quicker, and have better communication with complainants, and other interested parties.
Aside from the very important personal tragedies of the families involved, episodes like this lead to a loss of confidence in the NHS, and the caring professions. A wider management concentration on peripheral, albeit important, issues highlighted by the department of health must not be allowed to distract from the core purpose of the NHS: to provide as much high quality healthcare to patients as they need. Had the patient remained at the centre of the health care process, had there not been a gross failure of clinical leadership at all levels, had there been more robust interest from the various external and regulatory bodies, it is possible that some of these deaths may have been prevented.
Anaesthetists work as a key part in many multidisciplinary teams. We must ensure that we personally highlight concerns when they arise, in order to protect our patients.
- Professional Standards Authority” Lessons Learned Review The Nursing and Midwifery Council’s handling of concerns about midwives’ fitness to practise at the Furness General Hospital” May 2018 https://www.professionalstandards.org.uk/docs/default-source/publications/special-review-report/nmc-lessons-learned-review-may-2018.pdf?sfvrsn=a2177220_5 accessed July 2018
- Titcombe J Joshua’s Story. Uncovering the Morcambe Bay NHS Scandal Anderson Wallace Publishing 2015
- “Our hospitals: Furness General Hospital”. University Hospitals of Morecambe Bay NHS Foundation Trust. Retrieved 20 June 2013.
- “Basic Maternity Statistics For The Northwestern Region (2009)”. BirthChoiceUK. Archived from the originalon 18 January 2013. Retrieved 13 June 2018.
- Fielding D, Richens Y, Calder A Review of Maternity Services in University Hospitals of Morecambe Bay NHS Trust 2010Call for clarity on NHS funding pledge 28 march 2018 https://www.bma.org.uk/news/2018/march/call-for-clarity-on-nhs-funding-pledge accessed 16th July 2018
- Kirkup B The Report of the Morecambe Bay Investigation March 2015 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/408480/47487_MBI_Accessible_v0.1.pdf last accessed 19 July 2018
James Watts, BSc MB ChB FRCA FFICM, Consultant in Anaesthesia & Critical Care, East Lancashire NHS Trust