Department of Health, 3 March 2015
- The Morecambe Bay Investigation looked at the maternity and neonatal services in University Hospitals Morecambe Bay NHS Foundation Trust.
- Covering January 2004 to June 2013, Kirkup Report concludes the maternity unit at Furness General Hospital (FGH) was dysfunctional with serious problems in 5 main areas:
- Clinical competence of a proportion of staff fell significantly below the standard for a safe, effective service.
- Poor working relationships between midwives, obstetricians and paediatricians.
- Midwifery care became strongly influenced by a small number of dominant midwives whose ‘over-zealous’ pursuit of natural childbirth ‘at any cost’ led at times to unsafe care.
- Failures of risk assessment and care planning resulted in inappropriate and unsafe care.
- Grossly deficient response from unit clinicians to serious incidents with repeated failure to investigate properly and learn lessons.
- CCGs had not inherited a service specification from the PCTs and the absence of lead commissioning arrangements inherited from PCTs was found to have resulted in lack of effective communication between commissioners and performance issues being missed.
