The publication of the Report of the Morecambe Bay Investigation (also known as the Kirkup report) in March 2015 was a defining moment for our Trust.
The Morecambe Bay Investigation was established by the previous Secretary of State for Health to examine concerns raised by the occurrence of serious incidents in maternity services provided by UHMBT, including the deaths of mothers and babies, in the period between January 2004 and 2013.
The investigation was led by Dr Bill Kirkup CBE and the concerns covered three maternal deaths and the deaths of 16 babies at or shortly after birth. Dr Kirkup issued a report in March 2015 and identified significant concerns across a number of areas within the Trust, the wider NHS, professional and regulatory bodies. The report made 18 recommendations specific to the Trust and a further 26 to the wider NHS.
Whilst our teams have worked extremely hard to make significant improvements, there is still work to do. Our strategy is one of continual improvement and creating the right environment for our staff to be able to implement best practice and to have the confidence to raise concerns when standards are not being met.
We live and work amongst the people who use our services and we want to be their hospital and community service of choice - providing safe services in a compassionate way.
The Report of the Morecambe Bay Investigation was published on 3 March 2015 by Dr Bill Kirkup CBE. It identified significant concerns across several areas from within the Trust and further concerns from across the wider NHS, regulatory and professional bodies.
The problems within the Trust fell into five problem areas, which resulted in the service being described as seriously dysfunctional. These were:
- Clinical competence of a proportion of staff fell significantly below the standard required for a safe, effective service
- Working relationships between different groups of staff were extremely poor
- Midwifery care in the unit became strongly influenced by a small number of dominant individuals
- Advice to mothers that it was appropriate to consider delivery at FGH was significantly compromised by a failure to assess the risks properly
- A grossly deficient response from unit clinicians to serious incidents with repeated failure to investigate properly and learn lessons
The full report can be found on the Government’s website here.
It was important that we didn’t just accept the Kirkup report and then treat the recommendations as a ‘check list’ of actions - we owed it to everyone involved to demonstrate we would truly learn from it.
In April 2016, we published our ‘One year on - how we implemented the recommendations from the Kirkup report’ which updated on how teams across the Trust had worked together to implement the recommendations.
It contains many instances of changed and improved practice, examples of innovative approaches to the problems of our particular geography, and describes how we viewed the recommendations as the starting point for change, not the end point.
We always intended to do a review five years after the publication of the Kirkup report to allow us to see how we were progressing - not in implementing the recommendations but whether we had embedded them into our day to day practice. Unfortunately, due to the COVID-19 pandemic and pressures on clinical teams, this was delayed but was approved by the Trust Board at the end of December 2020.
The panel that carried out the piece of work was made up of seven individuals with expertise and experience in areas such as engagement with service users, maternity, nursing, safeguarding, and anaesthetics.
It is important to note that this was not intended to be a service review but a defined piece of work commissioned by the Trust Board focused on whether the implementation of the 18 Trust Kirkup recommendations had been sustained to this day. The Care Quality Commission - who regulates all health and social care services - recently carried out an inspection of some of our services, including maternity. We are still awaiting the final findings from this inspection, which may include recommendations for further improvements.
The panel were asked to assess each recommendation to decide whether:
- The recommendations that were implemented following the publication of the report in 2015 were still fully embedded in practice
- The recommendations had been superseded by more up to date evidence based practice and if this was the case, was the evidence there to support this being embedded at the Trust
The panel reviewed an extensive amount of evidence supported through interviews and focus groups with various individuals and teams, including service users, colleagues, regulators, and stakeholders; as well as looking at data, documents and information.
After reviewing all of the evidence, the panel concluded that the Trust had ‘fully sustained’ 15 of the 18 recommendations, with the three remaining recommendations being ‘partly met’.
In addition, the Trust asked the panel to consider and make a judgement against three additional questions around how the Trust handles adverse incidents, whether there is evidence of continued improvements; and how culture and behaviours in maternity services were progressing. For each of the three additional areas, the panel acknowledged significant progress, with some actions identified to improve further recommended.