Public Inquiry Recommendations

1 Accepted

Morecambe Bay Investigation (2015)

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 …

- In July 2015, the government stated that the Trust had "formally admitted the extent and nature of the problems that occurred and apologised individually …

2 Accepted

Morecambe Bay Investigation (2015)

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 …

- In July 2015, the government stated that a review of skills, knowledge, competencies and professional duties of care had been "started" and was to …

3 Accepted

Morecambe Bay Investigation (2015)

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, …

- In July 2015, the government stated that the Trust was putting "substantial plans in place" including staff training and development programmes (Learning Not Blaming, …

4 Accepted

Morecambe Bay Investigation (2015)

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 …

- In July 2015, the government stated that the Trust was addressing continuing professional development requirements, to be completed by September 2015 (Learning Not Blaming, …

5 Accepted

Morecambe Bay Investigation (2015)

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 …

- In July 2015, the government stated that the Trust had "started to strengthen multi-disciplinary working - in particular between paediatricians, midwives, obstetricians and neonatal …

6 Accepted

Morecambe Bay Investigation (2015)

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 …

- In July 2015, the government stated that the Trust was addressing risk assessment protocols in maternity services (Learning Not Blaming, Cm 9113, Department of …

7 Accepted

Morecambe Bay Investigation (2015)

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, …

- In July 2015, the government stated that the Trust was putting plans in place to audit maternity and paediatric services against risk assessment protocols, …

8 Accepted

Morecambe Bay Investigation (2015)

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. …

- In July 2015, the government stated that the Trust was developing a recruitment and retention strategy, to be completed by January 2016 (Learning Not …

9 Accepted

Morecambe Bay Investigation (2015)

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 …

- In July 2015, the government stated that the Trust was addressing joint working between its main hospital sites (Learning Not Blaming, Cm 9113, Department …

10 Accepted

Morecambe Bay Investigation (2015)

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 …

- In July 2015, the government stated that the Trust was establishing partnerships with other trusts for learning and mentoring (Learning Not Blaming, Cm 9113, …

11 Accepted

Morecambe Bay Investigation (2015)

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 …

- In July 2015, the government stated that the Trust had "begun to review how investigations into incidents are carried out and started a programme …

12 Accepted

Morecambe Bay Investigation (2015)

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 …

- In July 2015, the government stated that the Trust had "begun to review how investigations into incidents are carried out" (Learning Not Blaming, Cm …

13 Accepted

Morecambe Bay Investigation (2015)

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 …

- In July 2015, the government stated that the Trust was improving complaints handling processes (Learning Not Blaming, Cm 9113, Department of Health, July 2015). …

14 Accepted

Morecambe Bay Investigation (2015)

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 …

- In July 2015, the government stated that the Trust had "reviewed clinical leadership in terms of individuals and structures in obstetrics, paediatrics and midwifery" …

15 Accepted

Morecambe Bay Investigation (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, …

- In July 2015, the government stated that the Trust was continuing governance systems work, including clinical governance (Learning Not Blaming, Cm 9113, Department of …

16 Accepted

Morecambe Bay Investigation (2015)

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 …

- In July 2015, the government stated that the Trust was clarifying manager roles and responsibilities in relation to quality (Learning Not Blaming, Cm 9113, …

17 Accepted

Morecambe Bay Investigation (2015)

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 …

- In July 2015, the government stated that the Trust was addressing the physical environment of the delivery suite at Furness General Hospital (Learning Not …

18 Accepted

Morecambe Bay Investigation (2015)

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 …

- In July 2015, the government stated that the Trust was "working closely with the Care Quality Commission, Monitor, NHS England and others" to implement …

19 Accepted

Morecambe Bay Investigation (2015)

Professional bodies review conduct of registrants

In light of the evidence we have heard during the Investigation, we consider that the professional regulatory bodies should review the findings of this Report in detail with a view …

- In July 2015, the government stated: "We accept this recommendation. Action is under way" and confirmed that the GMC and NMC had "reviewed the …

20 Accepted

Morecambe Bay Investigation (2015)

National review of maternity care in challenging circumstances

There should be a national review of the provision of maternity care and paediatrics in challenging circumstances, including areas that are rural, difficult to recruit to, or isolated. This should …

- In July 2015, the government stated: "We accept this recommendation" and confirmed that NHS England had begun a national review of maternity care chaired …

21 Accepted

Morecambe Bay Investigation (2015)

Consider extending review to other rural services

The challenge of providing healthcare in areas that are rural, difficult to recruit to or isolated is not restricted to maternity care and paediatrics. We recommend that NHS England consider …

- In July 2015, the government stated: "We accept this recommendation in principle" and described the establishment of Vanguard sites to explore new care models …

22 Accepted

Morecambe Bay Investigation (2015)

Recognise educational opportunities in smaller units

We believe that the educational opportunities afforded by smaller units, particularly in delivering a broad range of care with a high personal level of responsibility, have been insufficiently recognised and …

- In July 2015, the government stated: "We accept this recommendation in principle" and confirmed that Health Education England had established a working group to …

23 Accepted

Morecambe Bay Investigation (2015)

Clear standards for incident reporting in maternity

Clear standards should be drawn up for incident reporting and investigation in maternity services. These should include the mandatory reporting and investigation as serious incidents of maternal deaths, late and …

- In July 2015, the government stated: "We accept this recommendation in principle" and announced a new Independent Patient Safety Investigation Service to supplement existing …

24 Accepted

Morecambe Bay Investigation (2015)

Involve patients and relatives in incident investigation

We commend the introduction of the duty of candour for all NHS professionals. This should be extended to include the involvement of patients and relatives in the investigation of serious …

- In July 2015, the government stated: "We accept this recommendation" and confirmed that the organisational duty of candour was now in force as a …

25 Accepted

Morecambe Bay Investigation (2015)

Duty to report external investigation findings

We recommend that a duty should be placed on all NHS Boards to report openly the findings of any external investigation into clinical services, governance or other aspects of the …

- In July 2015, the government stated: "We accept these recommendations" (covering recs 25 and 42) and described existing reporting requirements and plans to extend …

26 Accepted

Morecambe Bay Investigation (2015)

Clear national whistleblowing policy

We commend the introduction of a clear national policy on whistleblowing. As well as protecting the interests of whistleblowers, we recommend that this is implemented in a way that ensures …

- In July 2015, the government stated: "We accept this recommendation" and described measures to implement the Freedom to Speak Up principles (Learning Not Blaming, …

27 Accepted

Morecambe Bay Investigation (2015)

Professional duty to report concerns

Professional regulatory bodies should clarify and reinforce the duty of professional staff to report concerns about clinical services, particularly where these relate to patient safety, and the mechanism to do …

- In July 2015, the government stated: "We accept this recommendation" and noted that a review of professional codes was under way (Learning Not Blaming, …

28 Accepted

Morecambe Bay Investigation (2015)

National standards for clinical leads

Clear national standards should be drawn up setting out the professional duties and expectations of clinical leads at all levels, including, but not limited to, clinical directors, clinical leads, heads …

- In July 2015, the government stated: "We accept these recommendations in principle" (covering recs 28 and 29) and described work between the Department of …

29 Accepted

Morecambe Bay Investigation (2015)

Standards for manager quality responsibilities

Clear national standards should be drawn up setting out the responsibilities for clinical quality of other managers, including executive directors, middle managers and non-executives. All Trusts should provide evidence to …

- In July 2015, the government stated: "We accept these recommendations in principle" (covering recs 28 and 29) and described the renewed focus on leadership …

30 Accepted

Morecambe Bay Investigation (2015)

National protocol on duties relating to inquests

A national protocol should be drawn up setting out the duties of all Trusts and their staff in relation to inquests. This should include, but not be limited to, the …

- In July 2015, the government stated: "We accept this recommendation in principle" and said it would "give further thought, with the Ministry of Justice …

31 Accepted

Morecambe Bay Investigation (2015)

Fundamental review of NHS complaints system

The NHS complaints system in the University Hospitals of Morecambe Bay NHS Foundation Trust failed relatives at almost every turn. Although it was not within our remit to examine the …

- In July 2015, the government stated: "We accept this recommendation in principle" but stated it did "not believe that another fundamental review will help" …

32 Accepted

Morecambe Bay Investigation (2015)

Reform Local Supervising Authority for midwives

The Local Supervising Authority system for midwives was ineffectual at detecting manifest problems at the University Hospitals of Morecambe Bay NHS Foundation Trust, not only in individual failures of care …

- In July 2015, the government stated: "We accept this recommendation. We will therefore modernise the regulatory regime for midwifery" (Learning Not Blaming, Cm 9113, …

33 Accepted

Morecambe Bay Investigation (2015)

CQC and Monitor coordination

We considered carefully the effectiveness of separating organisationally the regulation of quality by the Care Quality Commission from the regulation of finance and performance by Monitor, given the close inter-relationship …

- In July 2015, the government stated: "We accept this recommendation" and noted that an updated Memorandum of Understanding between Monitor and the CQC had …

34 Accepted

Morecambe Bay Investigation (2015)

CQC and PHSO memorandum of understanding

The relationship between the investigation of individual complaints and the investigation of the systemic problems that they exemplify gave us cause for concern, in particular the breakdown in communication between …

- In July 2015, the government stated: "We accept this recommendation" and confirmed that a new Memorandum of Understanding between the CQC and PHSO had …

35 Accepted

Morecambe Bay Investigation (2015)

Clarify oversight responsibilities

The division of responsibilities between the Care Quality Commission and other parts of the NHS for oversight of service quality and the implementation of measures to correct patient safety failures …

- In July 2015, the government stated: "We accept this recommendation in principle" and described actions to clarify oversight responsibilities (Learning Not Blaming, Cm 9113, …

36 Accepted

Morecambe Bay Investigation (2015)

Impact assessment of policy changes

The cumulative impact of new policies and processes, particularly the perceived pressure to achieve Foundation Trust status, together with organisational reconfiguration, placed significant pressure on the management capacity of the …

- In July 2015, the government stated: "We accept this recommendation in principle" and acknowledged that "the pursuit of Foundation Trust status distorted management capacity …

37 Accepted

Morecambe Bay Investigation (2015)

Protocol for organisational change transitions

Organisational change that alters or transfers responsibilities and accountability carries significant risk, which can be mitigated only if well managed. We recommend that an explicit protocol be drawn up setting …

- In July 2015, the government stated: "We accept this recommendation" and referenced existing guidance issued in September 2011 on management of records during organisational …

38 Accepted

Morecambe Bay Investigation (2015)

Improve perinatal mortality recording

Mortality recording of perinatal deaths is not sufficiently systematic, with failures to record properly at individual unit level and to account routinely for neonatal deaths of transferred babies by place …

- In July 2015, the government stated: "We accept this recommendation" and confirmed that MBRRACE-UK had established a system to systematically collect and report surveillance …

39 Accepted

Morecambe Bay Investigation (2015)

Implement medical examiner system

There is no mechanism to scrutinise perinatal deaths or maternal deaths independently, to identify patient safety concerns and to provide early warning of adverse trends. This shortcoming has been clearly …

- In July 2015, the government stated: "We accept these recommendations in principle" (covering recs 39 and 40) and confirmed that the medical examiner system …

40 Accepted

Morecambe Bay Investigation (2015)

Extend medical examiners to stillbirths

Given that the systematic review of deaths by medical examiners should be in place, as above, we recommend that this system be extended to stillbirths as well as neonatal deaths, …

- In July 2015, the government stated: "We accept these recommendations in principle" (covering recs 39 and 40) but noted that "medical examiners would scrutinise …

41 Accepted

Morecambe Bay Investigation (2015)

Guidance for external service reviews

We were concerned by the ad hoc nature and variable quality of the numerous external reviews of services that were carried out at the University Hospitals of Morecambe Bay NHS …

- In July 2015, the government stated: "We accept this recommendation" and noted that the Serious Incident Framework (March 2015) set out details of when …

42 Accepted

Morecambe Bay Investigation (2015)

Register external reviews with CQC

We further recommend that all external reviews of suspected service failures be registered with the Care Quality Commission and Monitor, and that the Care Quality Commission develops a system to …

- In July 2015, the government stated: "We accept these recommendations" (covering recs 25 and 42) and stated it would "consult on proposals to extend …

43 Accepted

Morecambe Bay Investigation (2015)

Maintain focus on quality

We strongly endorse the emphasis placed on the quality of NHS services that began with the Darzi review, High Quality Care for All, and gathered importance with the response to …

- In July 2015, the government stated: "We accept this recommendation, and strongly agree that the emphasis on quality of care must be maintained" (Learning …

44 Accepted

Morecambe Bay Investigation (2015)

Establish framework for future investigations

This Investigation was hampered at the outset by the lack of an established framework covering such matters as access to documents, the duty of staff and former staff to cooperate, …

- In July 2015, the government stated: "We accept this recommendation in principle" and announced the establishment of the Independent Patient Safety Investigation Service (Learning …