[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:
10 http://www.uhmb.nhs.uk/morecambe-bay-investigation/implementing-the-recommendations/
• 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).
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