Reports & recommendations
44 recommendations, each with the government response on the record. Filter by government response or delivery status.
Reports (1)
| Title | Volume | Publication Date | Recommendations | Links |
|---|---|---|---|---|
| Report of the Morecambe Bay Investigation | Final | 03 Mar 2015 | 44 |
Recommendations (18)
Admit problems and apologise to affected families
The University Hospitals of Morecambe Bay NHS Foundation Trust should formally admit the extent and nature of the problems that have previously occurred, and should apologise to those patients and relatives affected, not only for the avoidable damage caused but also for the length of time it has taken to bring them to light and the previous failures to act. This should begin immediately with the response to this Report.
In commentary provided in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, noting that action had been taken and that University Hospitals of Morecambe Bay NHS Foundation Trust entered the Maternity Safety Support Programme in 2021 (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team found evidence of implementation, citing the department's July 2015 report stating that the trust had formally admitted the problems and apologised individually to families (Department of Health response, Jul 2015; The Thirlwall Inquiry legal team, May 2024).
Review clinical staff competencies
The University Hospitals of Morecambe Bay NHS Foundation Trust should review the skills, knowledge, competencies and professional duties of care of all obstetric, paediatric, midwifery and neonatal nursing staff, and other staff caring for critically ill patients in anaesthetics and intensive and high dependency care, against all relevant guidance from professional and regulatory bodies. This review should be completed by June 2015, and identify requirements for additional training, development and, where necessary, a period of experience elsewhere.
In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was implemented and closed, stating that action taken in response had been noted (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team found in February 2026 that University Hospitals of Morecambe Bay NHS Foundation Trust had established an education, learning and development project following the investigation (The Thirlwall Inquiry legal team, Feb 2026). It reported that this project set explicit training expectations across women's and children's services and related teams, created a central training management system, and introduced preceptorship and leadership programmes (The Thirlwall Inquiry legal team, Feb 2026).
Deliver staff training and development plans
The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up plans to deliver the training and development of staff identified as a result of the review of maternity, neonatal and other staff, and should identify opportunities to broaden staff experience in other units, including by secondment and by supernumerary practice. These should be in place in time for June 2015.
In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that the Thirlwall Inquiry had noted action taken in response to the recommendation (DHSC and NHS England, Feb 2026). In its February 2026 review, the inquiry legal team found that University Hospitals of Morecambe Bay NHS Foundation Trust had put in place an education, learning, and development project by April 2016, establishing explicit training expectations, a central training management system, and leadership and preceptorship programmes (The Thirlwall Inquiry legal team, Feb 2026).
Establish continuing professional development requirements
Following completion of additional training or experience where necessary, the University Hospitals of Morecambe Bay NHS Foundation Trust should identify requirements for continuing professional development of staff and link this explicitly with professional requirements including revalidation. This should be completed by September 2015.
In commentary submitted in September 2024, the Department of Health and Social Care and NHS England stated that the recommendation was complete, recording that action taken had been noted (DHSC and NHS England, Feb 2026). In a review published in February 2026, the Thirlwall Inquiry legal team found that University Hospitals of Morecambe Bay NHS Foundation Trust had put in place the Kirkup Education Learning and Development Project by April 2016 (The Thirlwall Inquiry legal team, Feb 2026). It found that this project agreed explicit training expectations, developed a central training management system to monitor compliance, and introduced preceptorship and leadership development programmes (The Thirlwall Inquiry legal team, Feb 2026).
Promote effective multidisciplinary team-working
The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and develop measures that will promote effective multidisciplinary team-working, in particular between paediatricians, obstetricians, midwives and neonatal staff. These measures should include, but not be limited to, joint training sessions, clinical, policy and management meetings and staff development activities. Attendance at designated events must be compulsory within terms of employment. These measures should be identified by April 2015 and begun by June 2015.
In commentary provided in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England classified the recommendation as implemented and closed, stating that the Thirlwall Inquiry had noted action taken in response to it (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team found that the Trust had taken action to address the recommendation, noting the establishment of a Clinical Quality Project overseen by an Executive Nurse Director (The Thirlwall Inquiry legal team, May 2024).
Draw up maternity risk assessment protocol
The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up a protocol for risk assessment in maternity services, setting out clearly: who should be offered the option of delivery at Furness General Hospital and who should not; who will carry out this assessment against which criteria; and how this will be discussed with pregnant women and families. The protocol should involve all relevant staff groups, including midwives, paediatricians, obstetricians and those in the receiving units within the region. The Trust should ensure that individual decisions on delivery are clearly recorded as part of the plan of care, including what risk factors may trigger escalation of care, and that all Trust staff are aware that they should not vary decisions without a documented risk assessment. This should be completed by June 2015.
In February 2026, DHSC and NHS England recorded the recommendation as implemented and closed, stating that the Thirlwall Inquiry had noted action taken in response (DHSC and NHS England, Feb 2026). In May 2024, the inquiry's legal team found that the Trust had refreshed and standardised clinical guidance on antenatal and intrapartum risk assessments across its maternity units (The Thirlwall Inquiry legal team, May 2024). Previously, in June 2021, University Hospitals of Morecambe Bay NHS Foundation Trust reported that a review panel considered the recommendation would be fully met once a dedicated electronic patient record for maternity was introduced (University Hospitals of Morecambe Bay NHS Foundation Trust, Jun 2021).
Audit maternity and paediatric services
The University Hospitals of Morecambe Bay NHS Foundation Trust should audit the operation of maternity and paediatric services, to ensure that they follow risk assessment protocols on place of delivery, transfers and management of care, and that effective multidisciplinary care operates without inflexible demarcations between professional groups. This should be in place by September 2015.
In commentary submitted in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed (DHSC and NHS England, Feb 2026). The Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented, citing earlier work by University Hospitals of Morecambe Bay NHS Foundation Trust to refresh and standardise risk assessment guidance across maternity units (The Thirlwall Inquiry legal team, May 2024). Previously, the Trust had reported in June 2021 that an internal review panel considered the recommendation would be fully met once a dedicated electronic patient record for maternity was introduced (University Hospitals of Morecambe Bay NHS Foundation Trust, Jun 2021).
Develop recruitment and retention strategy
The University Hospitals of Morecambe Bay NHS Foundation Trust should identify a recruitment and retention strategy aimed at achieving a balanced and sustainable workforce with the requisite skills and experience. This should include, but not be limited to, seeking links with one or more other centre(s) to encourage development of specialist and/or academic practice whilst offering opportunities in generalist practice in the Trust; in addition, opportunities for flexible working to maximise the advantages of close proximity to South Lakeland should be sought. Development of the strategy should be completed by January 2016.
In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, stating that the Thirlwall Inquiry had noted action taken in response to it (DHSC and NHS England, Feb 2026). In May 2024, that inquiry's legal team found that University Hospitals of Morecambe Bay NHS Foundation Trust had developed a recruitment and retention strategy across partner organisations and reviewed employment contracts to provide flexible working (The Thirlwall Inquiry legal team, May 2024).
Improve joint working between hospital sites
The University Hospitals of Morecambe Bay NHS Foundation Trust should identify an approach to developing better joint working between its main hospital sites, including the development and operation of common policies, systems and standards. Whilst we do not believe that the introduction of extensive split-site responsibilities for clinical staff will do much other than lead to time wasted in travelling, we do consider that, as part of this approach, flexibility should be built into working responsibilities to provide temporary solutions to short-term staffing problems. This approach should be begun by September 2015.
In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that the recommendation was implemented and closed, recording that the Thirlwall Inquiry had noted action taken in response (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the recommendation had been clearly implemented, citing the Trust's development of cross-bay obstetric and midwifery guidelines and Bay-wide procedural documents (The Thirlwall Inquiry legal team, May 2024).
Establish partner Trust buddying arrangement
The University Hospitals of Morecambe Bay NHS Foundation Trust should seek to forge links with a partner Trust, so that both can benefit from opportunities for learning, mentoring, secondment, staff development and sharing approaches to problems. This arrangement is promoted and sometimes facilitated by Monitor as 'buddying' and we endorse the approach under these circumstances. This could involve the same centre identified as part of the recruitment and retention strategy. If a suitable partner is forthcoming, this arrangement should be begun by September 2015.
In February 2026, the Department of Health and Social Care and NHS England reported that the recommendation was implemented, stating that the Thirlwall Inquiry had noted action taken in response (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the inquiry's legal team found that the measure had been clearly implemented, citing an April 2016 report in which the Trust confirmed strategic partnerships with Central Manchester University Hospitals NHS Foundation Trust and Lancashire Teaching Hospitals NHS Foundation Trust (The Thirlwall Inquiry legal team, May 2024).
Raise awareness of incident reporting and duty of candour
The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and implement a programme to raise awareness of incident reporting, including requirements, benefits and processes. The Trust should also review its policy of openness and honesty in line with the duty of candour of professional staff, and incorporate into the programme compliance with the refreshed policy. This should be begun with maternity staff by April 2015 and rolled out to other staff by April 2016.
In September 2024, in commentary published in February 2026, the Department of Health and Social Care and NHS England stated that the recommendation was implemented and closed, noting that the Thirlwall Inquiry had recorded action taken (DHSC and NHS England, Feb 2026). Previously, in May 2024, the inquiry legal team found that the measure had been clearly implemented, citing a July 2015 report in which the department noted that the Trust had begun an awareness programme with maternity staff (Department of Health response, Jul 2015; The Thirlwall Inquiry legal team, May 2024).
Review incident investigation structures
The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in investigating incidents, carrying out root cause analyses, reporting results and disseminating learning from incidents, identifying any residual conflicts of interest and requirements for additional training. The Trust should ensure that robust documentation is used, based on a recognised system, and that Board reports include details of how services have been improved in response. The review should include the provision of appropriate arrangements for staff debriefing and support following a serious incident. This should be begun with maternity units by April 2015 and rolled out across the Trust by April 2016.
In commentary submitted in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, stating that the Thirlwall Inquiry had noted action taken in response (DHSC and NHS England, Feb 2026). In May 2024, the inquiry's legal team noted that University Hospitals of Morecambe Bay NHS Foundation Trust had begun reviewing incident investigation procedures with maternity staff (The Thirlwall Inquiry legal team, May 2024). The Trust had previously stated in June 2021 that a review panel would consider the recommendation fully met once action plans were complete and audits showed sustained improvement, which was due by June 2022 (University Hospitals of Morecambe Bay NHS Foundation Trust, Jun 2021).
Improve complaints handling
The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in responding to complaints, and introduce measures to promote the use of complaints as a source of improvement and reduce defensive 'closed' responses to complainants. The Trust should increase public and patient involvement in resolving complaints, in the case of maternity services through the Maternity Services Liaison Committee. This should be completed, and the improvements demonstrated at an open Board meeting, by December 2015.
In commentary provided in September 2024 and published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented, stating that the Thirlwall Inquiry had noted action taken in response to it (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the recommendation had been implemented, citing a 2016 Trust report that confirmed complaints procedures had been aligned with ombudsman guidelines, case officers had been assigned to liaise with complainants, and regular audits had been introduced (The Thirlwall Inquiry legal team, May 2024).
Review clinical leadership arrangements
The University Hospitals of Morecambe Bay NHS Foundation Trust should review arrangements for clinical leadership in obstetrics, paediatrics and midwifery, to ensure that the right people are in place with appropriate skills and support. The Trust has implemented change at executive level, but this needs to be carried through to the levels below. All staff with defined responsibilities for clinical leadership should show evidence of attendance at appropriate training and development events. This review should be commenced by April 2015.
In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as completed, stating that action taken had been noted (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team found evidence that the recommendation had been clearly implemented, citing earlier reporting (The Thirlwall Inquiry legal team, May 2024). The department had previously reported in July 2015 that University Hospitals of Morecambe Bay NHS Foundation Trust had reviewed clinical leadership across obstetrics, paediatrics and midwifery (Department of Health response, Jul 2015).
Continue governance systems work
The University Hospitals of Morecambe Bay NHS Foundation Trust should continue to prioritise the work commenced in response to the review of governance systems already carried out, including clinical governance, so that the Board has adequate assurance of the quality of care provided by the Trust's services. This work is already underway with the facilitation of Monitor, and we would not seek to vary or add to it, which would serve only to detract from implementation. We do, however, recommend that a full audit of implementation be undertaken before this is signed off as completed.
In commentary from September 2024, published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, noting that the Thirlwall Inquiry had recognized action taken in response (DHSC and NHS England, Feb 2026). The inquiry's legal team found in May 2024 that University Hospitals of Morecambe Bay NHS Foundation Trust had standardized its audit process and that an internal audit programme had reviewed governance processes during 2014 and 2015 (The Thirlwall Inquiry legal team, May 2024).
Clarify manager quality responsibilities
As part of the governance systems work, we consider that the University Hospitals of Morecambe Bay NHS Foundation Trust should ensure that middle managers, senior managers and non-executives have the requisite clarity over roles and responsibilities in relation to quality, and it should provide appropriate guidance and where necessary training. This should be completed by December 2015.
In September 2024 commentary published in February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, stating that the Thirlwall Inquiry had noted action taken in response (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the inquiry legal team found that the recommendation was implemented, citing an April 2016 trust update showing that non-executive directors chaired sub-board assurance committees and annual mandatory risk management training had been established (The Thirlwall Inquiry legal team, May 2024).
Improve Furness General Hospital delivery suite
The University Hospitals of Morecambe Bay NHS Foundation Trust should identify options, with a view to implementation as soon as practicable, to improve the physical environment of the delivery suite at Furness General Hospital, including particularly access to operating theatres, an improved ability to observe and respond to all women in labour and en suite facilities; arrangements for post-operative care of women also need to be reviewed. Plans should be in place by December 2015 and completed by December 2017.
In February 2026, the Department of Health and Social Care and NHS England recorded the recommendation as implemented and closed, stating that the Thirlwall Inquiry had noted action taken in response (DHSC and NHS England, Feb 2026). In May 2024, that inquiry's legal team found that the recommendation had been clearly implemented, citing University Hospitals of Morecambe Bay NHS Foundation Trust's 2016 plans for a new build with handover scheduled for November 2017 (The Thirlwall Inquiry legal team, May 2024).
Ensure external oversight of implementation
All of the previous recommendations should be implemented with the involvement of Clinical Commissioning Groups, and where necessary, the Care Quality Commission and Monitor. In the particular circumstances surrounding the University Hospitals of Morecambe Bay NHS Foundation Trust, NHS England should oversee the process, provide the necessary support, and ensure that all parties remain committed to the outcome, through an agreed plan with the Care Quality Commission, Monitor and the Clinical Commissioning Groups.
In September 2024 commentary published in February 2026, NHS England and the Department of Health and Social Care recorded the recommendation as implemented and closed, stating that the Thirlwall Inquiry had noted action taken in response to it (DHSC and NHS England, Feb 2026). Earlier, that inquiry's legal team found in May 2024 that the recommendation had been clearly implemented, citing the department's July 2015 response which confirmed that the hospital trust was working closely with the Care Quality Commission and Monitor (Department of Health response, Jul 2015; The Thirlwall Inquiry legal team, May 2024).