Recommendation 2: Review clinical staff competencies
From Report of the Morecambe Bay Investigation, published 3 March 2015.
Recommendation
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 brief (written by this site)
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).
AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026. The record below is the sources' own words.
Government response
[A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm to mothers and babies including unnecessary deaths, and found that there was a pattern of Trust failure to recognise the severity and nature of the problem, compounded by denial. The Trust failed to look into serious incidents and sought to diminish the seriousness of the situation to others. At the Trust level there were failures in risk assessment and care planning; a deficient response to adverse incidents; and failure to investigate and improve. The Investigation Report, published on 3 March 2015, challenged the Trust to make a number of improvements quickly. 2. The Trust had earlier been placed into special measures in July 2014 following the Care Quality Commission inspection of February 2014. This means that they have to have made real improvements by the next Care Quality Commission inspection in July 2015. An Improvement Director appointed by Monitor provides constructive challenge as part of the process. The Care Quality Commission will publish their judgment of the Trust in the autumn. 3. To address both the requirements of special measures and the Morecambe Bay Investigation recommendations, the Trust has put substantial plans in place to make improvements. Delivery of these plans is overseen by several groups including a "Kirkup Recommendations Implementation Group". The Group reports to the Morecambe Bay Investigation sub-committee, which is a sub-committee of the Trust Board and the local Quality Surveillance Group (QSG), chaired by local NHS England representatives and ensuring that the Trust, clinical commissioning groups (CCGs), regulators and others are working together in the best interests of the local population. Progress reports are publicly available10. The Trust has taken care to involve affected families in groups looking at how their services can be made more effective and patient-centred. 4. The Trust is being inspected by the Care Quality Commission in July 2015 and it would be wrong to speculate whether sufficient progress will have been made by then. However the Trust reports that they have so far: • Formally admitted the extent and nature of the problems that occurred and apologised individually to families (recommendation 1); • Started to strengthen multi-disciplinary working - in particular between paediatricians, midwives, obstetricians and neonatal staff – as part of a broader, ongoing programme of work (recommendation 5); • With maternity staff, begun to review how investigations into incidents are carried out and started a programme to raise awareness of incident reporting, (recommendations 11 & 12); • Reviewed clinical leadership in terms of individuals and structures in obstetrics, paediatrics and midwifery (recommendation 14); and • Ensured that in carrying out all of these, the Trust is working closely with the Care Quality Commission, Monitor, NHS England and others (recommendation 18).
How this response relates to the recommendation
Site note: This is the Department of Health's response, "Learning not blaming" (Cm 9113, July 2015), to the Morecambe Bay Investigation and two other reports. The department has been the Department of Health and Social Care since January 2018, and the rows are filed under that name. Every word is the department's, including where it reports what another body has done or will do.
Site note: The recommendation is addressed to University Hospitals of Morecambe Bay NHS Foundation Trust; the passage is the Department of Health's account, not that body's. The response gives this passage once, for the section "[A] Recommendations for the Trust", and the same words are recorded on each.
Delivery
DHSC and NHS England say completed (27 February 2026)
The Thirlwall Inquiry has noted action taken in response to this recommendation.
Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Implemented – Closed”. Table row: section 23.2 No. 2, PDF page 636.
Site note: DHSC and NHS England's entry for this recommendation says that the Thirlwall Inquiry noted action taken on it. The entry gives no other account of what was done.
What other bodies have found
In their own words. These do not change the delivery statement above.
Thirlwall Inquiry legal team (27 February 2026)
In the Trust’s ‘One Year on’ report (April 2016):
Implemented the Kirkup Education Learning and Development Project. Director of Workforce and Organisational Development responsible. (p. 66-73)
The project has led to:
• The agreement of clear and explicit training expectations, split into mandatory and essential role-specific training, for each of the professional staff groups in the women’s & children’s services [WACS] and in critical care; with clear performance monitoring to ensure that active management trajectories were in place to ensure compliance.
• The development of the training management system (TMS) to support the ongoing monitoring and management of all aspects of mandatory and role specific training on a real-time basis, with all training data captured in a single central resource.
• Preceptorships and leadership development programmes being implemented within the WACS division. (p. 66-73)
Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). The review colours its Extent of Implementation cell for this recommendation green, which it uses to mark evidence, identified by the legal team and/or DHSC and NHS England, that a recommendation has been clearly implemented. Table row: section 23.2 No. 2 (one merged cell for Nos. 2, 3, 4), PDF page 636.
Earlier findings (1)
Thirlwall Inquiry legal team (15 May 2024)
In the Trust’s ‘One Year on’ report (April 2016):
Implemented the Kirkup Education Learning and Development Project. Director of Workforce and Organisational Development responsible. (p. 66-73)
The project has led to:
• The agreement of clear and explicit training expectations, split into mandatory and essential role-specific training, for each of the professional staff groups in the women’s & children’s services [WACS] and in critical care; with clear performance monitoring to ensure that active management trajectories were in place to ensure compliance.
• The development of the training management system (TMS) to support the ongoing monitoring and management of all aspects of mandatory and role specific training on a real-time basis, with all training data captured in a single central resource.
• Preceptorships and leadership development programmes being implemented within the women’s and children’s services division. (p. 66-73)
Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review colours its Extent of Implementation cell for this recommendation green, which it uses to mark evidence, identified by the legal team, that a recommendation has been clearly implemented. Table row: section 20.2 No. 2 (one merged cell for Nos. 2, 3, 4), PDF page 592-593.
Source
Responsible bodies
Themes and tags
Who has spoken
- Department of Health and Social Care
Response - DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding