Ida Lock

Dear Dr Adeley

Regulation 28: Report To Prevent Future Deaths – Ida Jean Lock Conclusion of inquest 21 March 2025

Thank you for your letter dated 21 March 2025 sent following the conclusion of the inquest touching the death of Ida Jean Lock.

I know that you will share my response with Ida’s parents, and I first want to express my deep condolences to them along with a sincere apology for the added distress they have suffered as a result of the failure in clinical governance processes within University Hospitals of Morecambe Bay Trust.

NHS Lancashire and South Cumbria Integrated Care Board (ICB) are keen to assure the family and the coroner that the concerns raised about the care and clinical governance processes have been listened to, carefully reflected on and appropriately actioned.

Through the Regulation 28 report you have raised a number of matters of concern relating to the care that Ida and her mother received and clinical governance processes/practices in University Hospitals of Morecambe Bay Trust. This letter is in response to these issues, and I will respond to each matter raised separately.

A: Culture of Candour

1. There is not a culture of candour within University Hospitals of Morecambe Bay NHS Foundation Trust (Trust) and the impact that this has on safety, learning and implementing required changes to prevent deaths. Urgent action is required by the Trust to meaningfully embed the Dury of Candour. Being open and transparent with our population when something has gone wrong within healthcare is a priority nationally, regionally and locally. Measures are in place to monitor compliance with Duty of Candour through the NHS Standard Contract however Lancashire and South Cumbria Integrated Care Board (LSC ICB) also receive updates from the Trust around compliance with Duty of Candour through the Trusts Integrated Performance Report and attendance at their internal Quality Assurance Committee.

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Chair – Chief executive (interim) –

The ICB has identified that the Trust is currently showing common cause variation with the lower compliance attributed to staffing capacity. The capacity issue is being addressed through divisional reconfiguration and additional capacity was identified which came into effect on 1 April
2025. An audit has been undertaken and there is an associated action plan in order to improve compliance to ensure every patient/family is served Duty of Candour in a timely and compassionate manner. The ICB are committed to ensuring that compliance improves and will monitor the effectiveness of the action plan through continued mechanisms including attendance at the Trust Quality Assurance Committee providing external challenge and scrutiny.

2. 's evidence to the inquest was that a deep-seated and endemic culture within the Trust leads to denial and a failure to learn. Following the Care Quality Commissions (CQC) Inspection of Maternity Services in 2021, the service was entered onto the national Maternity Safety Support Programme (MSSP). A full diagnostic assessment was undertaken by the Maternity Improvement Advisor (MIA) allocated to the service which identified several areas for focussed improvement work, including governance, culture and leadership. An associated improvement and sustainability plan has been developed, and the oversight and assurance are led by the national MSSP team. The LSC ICB Local Maternity and Neonatal System (LMNS) are integral to the oversight and assurance work reporting internally within the ICB on progress against this work and are committed to ensuring that the Trust are building a culture to ensure learning from all patient safety events and near misses.

In addition, the quadrumvirate completed the Perinatal Culture and Leadership Programme in 2023/2024; this was a national mandated training programme focused on improving the quality and safety of maternity and neonatal care. Following on from this the SCORE culture survey was undertaken with the development of an associated action plan. The service identified five themes and are progressing these via a phased approach. There is 6- monthly reporting to the LMNS on the progress against this action plan including any identified challenges. It is acknowledged that since the original survey there has been a change in the perinatal quadrumvirate, however the current quadrumvirate have been offered support via the Health Innovation Agency to access further training.

As an organisation the trust has worked with the National Recovery Support Programme (RSP) on the Well Led domain and engaged in various programmes of work to improve culture and learning including:

⦁ Improvements to the Freedom To Speak Up (FTSU) service ⦁ 'Leadership For All' development programme ⦁ Stroke service improvements ⦁ Restorative, Just and Learning Culture implementation ⦁ Organisational development work in Maternity Services ⦁ Refresh of organisational strategy and priorities ⦁ Executive leadership development programme ⦁ Service improvement programmes ⦁ Review of medical staffing ⦁ Embedding kindness project in 2022/23 which informed the Patient Experience strategy.

Improvements were monitored through a System Wide Improvement Board leading to movement from a national System Oversight Framework (SOF) 4 position to SOF 3 and there is continued oversight through the System Improvement Assurance Group (IAG).

Chair – Chief executive (interim) –

Additionally, the ICB are sighted on the improvements being made to embed the Patient Safety Incident Response Framework (PSIRF) which is focused on learning and compassionate engagement. We do however acknowledge that progress with PSIRF has been limited which in turn delays learning and improvements. In order to address this the ICB are aware that additional capacity has now been sought to ensure that investigations into patient safety events are conducted in a timely manner, and this is currently being closely monitored with appropriate challenge provided to the Trust at both internal Trust and external assurance meetings. Within the wider organisation the Trust attend and actively participate in the ICS Shared Learning Forum and Patient Safety Specialist meetings. The ICB will ensure that actions taken from these discussions are implemented.

3. The Trust's approach to the inquest has been one of a lack of transparency and openness, failure to provide relevant information and a failure to identify with candour the defective clinical governance processes that have operated at the Trust from 2019 to present day. The LMNS, (the maternity arm of the Integrated Care Board) has established and embedded a governance and reporting structure for all local maternity services. This includes a bi-monthly Quality Assurance Panel and Patient Safety Learning Group (see attached Terms of Reference). UHMBT maternity service are fully engaged and provide regular reporting on maternity and neonatal outcomes and patient safety incidents in order to maximise learning across the Integrated Care System (ICS).

The ICS Maternity Patient Safety Learning Group is a dedicated forum to share learning from incidents across the system which UHMBT actively participate via their reporting and dedicated case discussions. In addition, the LMNS is a member of UHMBT Maternity &Neonatal Improvement Group, at this meeting a review of evidence is undertaken against the improvement actions in line with MSSP Plan. Also, the LMNS is invited and attends the UHMBT quarterly quality review with MNSI where a review of completed investigations with a focus on the identified learning and improvement actions is discussed.

The ICB is sorry that the family and coroner experienced a lack of transparency and openness throughout; this is not the expectation of LSC ICB where we are working hard to implement and embed a culture of incident reporting to highlight opportunities for patient safety/experience to be improved. Particular attention will be focused with the Trust in ensuring assurance can be evidenced going forward.

4. The Trust did not disclose that they had failed to notify the external bodies namely the CQC and the then CCG [ICB] via StEIS and the Trust's internal Serious Incidents Reporting Investigation panel, none of which was noted by the Trust's Patient Safety Summits. In line with contractual and regulatory requirements LSC ICB expects all providers to report all patient safety events onto the Learning From Patient Safety Events (LFPSE) platform (this has replaced the National Reporting Learning System – NRLS). Where appropriate and in line with Trust local and national priorities, patient safety events must also be reported onto StEIS where the ICB is then notified. The ICB is very concerned to note from your findings that the Trust failed to fulfil these contractual and regulatory requirements. Since the inception of the ICB there has been a detailed oversight in the reporting of patient safety events from the Trust against expected reporting, with challenge where there has been unexpected variation. The ICB will continue to seek assurance from the Trust through the contractual route and by the ongoing scrutiny of patient safety events.

Chair – Chief executive (interim) –

Please be re-assured that specifically for maternity services, as part of the LMNS Patient Safety Learning Group, UHMBT Maternity service provide a two monthly report on all patient safety incidents. This includes any incidents that have met the national and local priorities of the trust PSIRF plan, MNSI investigations, and all other incidents that have had a maternity patient safety review.

It is understood by LSC ICB that Mersey Internal Audit Authority (MIAA) as external auditors are scheduled to undertake an audit on the Trust’s PSIRF progress in 2025/26; the ICB will seek a copy of the audit outcome and monitor the implementation of any resulting action plan.

5. Trust figures to the Board provided in 2025 stated that there were no complaints over 6 months old when the Trust at the time of the inquest have not responded to and ’s 1 June 2020 complaint with the Trust's failure to categorise Ida's death as only "Moderate Harm" (see point 4 above) cause me also to have concern about the reliability of Trust's data. The ICB acknowledges the concerns of the coroner in respect of reliability of data. In order to be re-assured on the validity of data either supplied to the ICB or in the public domain, triangulation of hard and soft information is undertaken. This also includes the use of a Soft Intelligence System across Lancashire and South Cumbria; issues can be raised that allow for consideration of further interrogation or collation/theme/trending to build a wider view of a service or provider. This system plus all the other information held gives an ability to validate information/data provided and where necessary provide external scrunty and challenge through formal contract meetings and Quality Review meetings.

A clinical audit report is presented to the Trust’s Quality Assurance Committee on a quarterly basis which includes audits on documentation. Where audit standards are not being met there are mechanisms in place to track actions and re-audit. The Trust also report on clinical data quality as part of their annual quality account and perform well for data accuracy against peers. The ICB will continue to use this way of working paying particular attention in the ongoing need for triangulation of all data sources.

B. Clinical Governance and Maternity Governance

6. The clinical governance arrangements at the Trust require urgent review to ensure the appropriate personnel are in place, with the necessary training and skills to deliver robust clinical governance to ensure patient safety in maternity care.

As previously described the maternity service is on and remain under the remit of the national MSSP programme. Since being on the programme, a full review of governance has been completed by MIAA with an associated improvement plan developed. A focussed project to develop and implement a Maternity Quality Governance and Accountability Framework was completed in April 2023; the aim of the framework is to ensure that the roles and responsibilities of staff are clearly defined within the outlined risk and incident management process. The ICB does acknowledge that because of the divisional re-configuration within the Trust particular attention will need to be paid by the LMNS to ensure that clinical governance for maternity services is not negatively impacted.

Chair – Chief executive (interim) –

7. The Trust did not undertake any examination of its own clinical governance processes, which were a principal area of concern, and which was identified to the Trust five months before the inquest commenced. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements, defensive attitudes and inappropriate self-congratulation.

The ICB is deeply saddened that the family of Ida were unnecessarily exposed to an extended court hearing as result of poor clinical governance within the Trust; we were very concerned to read the findings from the inquest and do not support poor governance practices. We are aware that there has been staffing vacancies/absences within the clinical governance team which we would partly attribute to the deficiencies identified. The ICB are assured that key governance posts have been recruited to and staff commenced in post (albeit interim in some cases). The ICB will continue to monitor the impact of this recruitment to assure itself that clinical governance practices are improved, embedded and sustained. Additionally, the ICB will attend internal Trust key committee meetings and ensure scrutiny is afforded and challenge given where these practices are seen.

Specific to maternity the Trust now has an Independent Senior Advocate whose role is to ensure that the voices of women and families are listened to, heard and acted upon by the maternity services. In UHMBT the Advocate provides a report to Trust Quality and Assurance Committee which the ICB attend. Particular focus on the effectiveness of the Advocate role will continue by the LMNS ensuring there is independent challenge and scrutiny.

8. Specific concerns relating to individual members of staff

As these concerns are relating to individual staff members the ICB believes that UHMBT are best placed to respond to the coroner concerns.

9. All investigations conducted by the Trust to date in respect of Ida’s death have been unskilled, superficial, brief, failed to identify issues and left the family without answers and were all features identified by the 2015 Kirkup Report. In view of the continuing culture at the Trust, this cause a significant concern that issues of safety and safeguarding are not properly considered, transparently engaged with and then addressed formally in respect of a child fatality and serious injury by the Trust. As stated earlier in this response the ICB acknowledges that the Trusts journey in implementing and embedding PSIRF, the frameworks principles and the training of investigators in line with national expectations is not as advanced as initially planned or expected. This includes the clear need for compassionate engagement that is timely, open and transparent when care goes wrong. We are re-assured by the Trust that there is a plan in place to address these gaps and will actively and robustly monitor the progress to fully meet the PSIRF expectations using both quantitative and qualitative intelligence sources.

Additional scrutiny is now provided by the ICB through attendance at internal Trust safety panel meetings where learning response reports are shared and discussed as to whether they meet the criteria as outlined in the national framework. Constructive challenge is consistently delivered by the ICB in a supportive manner in order to assure ourselves that the investigation and report are of good quality with particular focus on family/patient engagement and involvement in the process.

Chair – Chief executive (interim) –

In addition, the LMNS have implemented a system wide Patient Safety Learning Group, in which the UHMBT Maternity service provide a two monthly report on all patient safety incidents (as described earlier in this response).

The ICB can confirm that in line with the National Maternity Incentive Scheme the LMNS also undertake quarterly quality assurance visits to review evidence against each of 10 safety actions.

10. The Trust now uses the PSIRF model and is to appoint 3 whole time equivalent Response Leads by 30 September 2025. However, I remain concerned that the Trust has not fully engaged with the duty of candour such that I am not satisfied that the work on PSIRF to date has truly addressed the issues in respect of Trust’s investigations. The Trust implemented PSIRF in line with national guidelines and within the required timescale however the ICB is aware that further progression of this agenda has been delayed due to lack of suitably trained investigators. The ICB is required to assure itself on the quality of the investigation and the quality of the report; this is done through attendance at the Trust internal Learning Response Group where evidence is available of supportive challenge when ICB concerns are raised. Particular attention is focused on the transparency of the investigation/report and the engagement with the patient/family. The Trust recognise that further work is needed to ensure that investigators are trained to use and apply the Systems Engineering Initiative for Patient Safety (SEIPS) framework methodology in their investigations (or a suitable alternative such as the Yorkshire Contributing Factors Framework). We are pleased that the Trust now utilise Patient Safety Partners who are able to offer an independent view on patient safety matters, challenging where necessary and are also aware that is providing specific training for staff on compassionate engagement following a patient safety event.

The ICB will continue to scrutinise all patient safety reports, provide supportive challenge to ensure the principles of a positive patient safety culture and the PSIRF are fully embedded and sustained with the Trust.

C. Mandatory Training, expired training and remedial training

11, 12 and 13. The Trust do not have robust systems in place to ensure that any midwife who has not completed her mandatory training is subject to immediate action to ensure that all mandatory training is completed and is in date. There was no remedial training put in place for either the midwives involved in Ida's delivery and resuscitation or for the paediatric SHO after Ida’s death. This raises a significant concern that the Trust do not operate a system of remedial training when this inquest has identified remedial training was required.

It is acknowledged that whilst the LMNS has oversight and assurance of training in line with Training Needs Analysis (Maternity Incentive scheme safety action 8), this does not include mandatory training. The Director of Midwifery at UHMBT has provided reassurance to the LMNS that further actions are underway to ensure there is monthly reporting on mandatory maternity training with deep dives to understand those staff not compliant and immediate action taken to remedy this position. As an LMNS we will seek assurance through the monthly reporting process that all staff are compliant and where this is not the case the rationale and actions being taken to ensure patient safety.

Chair – Chief executive (interim) –

D: Grading of harm for incident reporting: Babies who have sustained hypoxic brain injury and undergo cooling

14. The Trust graded Ida’s level of harm as “moderate”, even after her death. This

grading should have been adjusted to "severe" by the Trust before Ida was

transferred to Royal Preston Hospital as the consultant paediatrician identified that

she had sustained a severe hypoxic ischaemic encephalopathy due to foetal

bradycardia.

15. There is a significant risk that if reporting is graded on harm alone, clinical care that

resulted in hypoxic brain damage during delivery and which was prevented by

therapeutic cooling, will not adequately identify the problems that caused the harm

during the delivery.

16. confirmed that nationally there is inconsistency in categorisation of harm for

babies who sustain a hypoxic injury due to foetal bradycardia in labour and who

require cooling and clarification guidance would assist prevent further maternity

deaths and ensure full and proper investigation of hypoxic injuries sustained in

labour.

As an ICB and LMNS we are aware that the ongoing challenges in the grading of harm, directives from the PSIRF and how this aligns to CQC is a recognised issue both nationally and regionally

The North-West Regional Chief Midwife is developing Maternity Guidance and Principles with the aim to ensure there is a consistent approach in the identification and reporting of incidents. The ICB are supportive of this work and are actively engaged with the regional work to reduce this known risk.

E. Funding for MSNI

17. But for the HSIB investigation report into Ida’s death admitted that Ida’s death due to failures by the Trust would never have come to light or resulted in an inquest.

18. The MSNI is now hosted by the CQC with funding secured for the next two years but no certainty as to ongoing funding after this date. These independent investigations by specialist skilled investigators into the most serious of events is an essential safeguard to the lives of mothers and unborn children.

19. Without an assurance that funding will continue beyond 2027 I am concerned that significant harm events to mothers and babies and deaths such as Ida's will go unrecorded and lessons that should be learned to prevent future maternal and baby deaths will go unnoticed, and there will be a risk of future maternity deaths.

LSC ICB fully support and acknowledge the important role that MSNI play in undertaking truly independent maternity investigations and the value that these investigations have. The funding for this service is led nationally and therefore the ICB are unable to offer any assurances on this matter.

Chair – Chief executive (interim) –

I am grateful to you for highlighting your concerns to me and I hope that by this letter, I have addressed your concerns, but should you require any further clarification or information, please do not hesitate to contact me.

Dear Dr Adeley Re Ida Jean Lock (Deceased) Thank you for your Prevention of Future Death Report dated 21 March 2025. Firstly, we would like to express our deepest condolences to the parents and family of Ida. We want to apologise for the lapses in care that resulted in her tragic death and the further harm we then caused by how we handled the investigation. We recognise the distress this has caused Ida’s loved ones and are truly sorry for this. We have accepted your findings and reviewed our practices, policies and procedures in light of these, so that we can identify where further changes need to be made. We are committed to learning from this tragic event and the issues identified during the inquest. For ease, our responses to your matters of concern follow under the headings used in your report. A: Culture of Candour Following Ida’s death, the Trust did not follow its own policies. We should have met with Ida’s parents at the start of the investigation process. We should have awaited the outcome of the Healthcare Safety Investigation Branch (HSIB) investigation. The internal investigation relied on flawed and unconventional Root Cause Analysis (RCA) methodology with a narrow scope. This resulted in a failure to identify and address the acts and omissions in care that contributed to Ida’s death in the conclusions reached. Once the HSIB report was available, the Trust should have accepted the findings in the report unreservedly and considered why the conclusions differed from those of the internal investigation. We acknowledge with deep regret that the tragic death of Ida and the manner in which we investigated the case, demonstrated the serious systemic failures that were present within our Trust. It is clear that culture contributed to defensiveness, and a failure to engage in

Westmorland General Hospital Burton Road

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INTERIM CHAIR:

Tel: 01539 732288

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meaningful learning from adverse events. This impeded our ability to take timely and appropriate action to prevent harm and failed those we were entrusted to care for. Specifically, we recognise the unacceptable failure to notify key external bodies—namely the Care Quality Commission (CQC) and the then Clinical Commissioning Group (now the Integrated Care Board (ICB) via the Strategic Executive Information System (StEIS). This omission not only breached statutory reporting duties but also deprived the wider health system of critical information necessary for oversight and learning. To reinforce a culture of candour within the Trust - where openness, honesty, and learning are embedded at all levels - we have implemented a range of measures that go beyond compliance and aim to change behaviours, mindsets, and systems. In addition, we continue to monitor the impact of these changes through ward to board governance arrangements. The changes we have made are detailed below. By embedding these measures, the Trust is taking deliberate and sustained action to move beyond a culture of defensiveness, towards one of honesty, accountability, and continuous learning. These steps are critical in restoring public confidence, supporting staff wellbeing, and, most importantly, ensuring safer care for our patients. The Duty of Candour process is now embedded across the organisation. The maternity service has consistently demonstrated that all women and their families receive duty of candour within 10 working days of an incident occurring. This is monitored via the Quality Governance Assurance Framework. There is a standardised formal duty of candour letter, and communication is regular, with a single point of contact for families to raise any questions or concerns. The completion of Duty of Candour responses across the wider Trust is monitored via the Quality Governance Assurance Framework and reported on at the Quality Assurance Committee. There has been a pilot project, where families have also been informed about the role of the Maternity and Neonatal Senior Independent Advocate (MNSIA), an external point of contact who provides support and assists with advocacy. The application of this was monitored via the Quality Governance Assurance Framework. This is a national pilot programme that has recently closed and we await information around its continuation. There was never any intention by the Trust to be lacking in transparency and openness in its approach to the inquest. However, it is recognised that issues were identified at the inquest, which had not been identified by the Trust’s own investigations, at which point it became evident that further information was relevant. Every effort was made to locate and share this information as swiftly as possible, as soon as its relevance was identified. Actions taken prior to the inquest: Strengthening Freedom to Speak Up (FTSU)
• Enhanced visibility and support: The FTSU Guardians and FTSU Champions are now more visible and accessible across clinical and non-clinical areas, providing staff with safe, confidential pathways to raise concerns.

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• Leadership responsiveness: Senior leaders regularly engage with FTSU data and themes to identify systemic issues and ensure swift action is taken.
• The FTSU team reports to the Board of Directors.
• Psychological safety training: Dedicated training has been introduced to help leaders and teams foster environments where staff feel safe to raise concerns without fear of blame or reprisal. Daily Triage and Cross-Care Group Reviews
• Multi-disciplinary daily triage meetings have been established to review new concerns, incidents, and patient feedback in real time. This ensures timely recognition of risk, early escalation, and coordinated responses.
• These reviews involve cross-care group participation, breaking down silos and promoting shared learning, transparency, and consistency in how patient safety concerns are addressed.
• The daily structure enables tracking of themes and emerging trends, helping to identify issues early and prevent escalation. Implementation of the Patient Safety Incident Response Framework (PSIRF)
• The Trust is actively implementing PSIRF, which marks a fundamental shift in how we respond to patient safety incidents.
• Focus on learning, not blame: PSIRF prioritises understanding 'what' and 'how' over 'who', reducing defensiveness and enabling open dialogue.
• Flexible, proportionate responses: The framework allows for different types of learning responses (e.g. thematic reviews, case note reviews, patient safety incident investigations), depending on the nature and impact of the incident.
• Co-produced investigations: We are involving patients, families, and staff in shaping the terms of reference and contributing to learning outcomes.
• Training and capacity building: Staff involved in incident responses are being trained under PSIRF principles to ensure quality, compassion, and consistency in approach. Cultural Leadership and Accountability
• Executive and board-level commitment to candour is now more visible, with regular walkarounds, open forums, and leadership-led safety conversations.
• Leadership performance reviews include assessment of behaviours that support psychological safety, candour, and learning.
• Quarterly culture reviews track staff perceptions and feedback, with action plans developed in collaboration with teams. Promoting a Culture of Transparency and Accountability Regular mortality reviews and triangulation meetings reinforce the message that every patient outcome matters, and that the organisation is committed to learning, not blame. When embedded in organisational culture, these forums:
• Foster trust among staff, patients, and families
• Support the principles of the Duty of Candour
• Promote reflective practice and continuous professional development.
• Contribute to better governance oversight and regulatory compliance.

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Enhancing Clinical Governance and Risk Management By ensuring that lessons learned from mortality reviews are discussed alongside other sources of intelligence, triangulation meetings play a central role in:
• Informing board-level decision-making
• Shaping training, staffing, and resourcing priorities
• Anticipating risk and preventing future harm In 2022, a structured process was implemented to monitor and track complaints within maternity services. This includes weekly meetings between the Patient Experience Team and maternity service representatives to ensure timely review and action. Service user feedback is collected from multiple sources, including:
• Formal complaints
• Concerns raised with the Patient Advice and Liaison Service (PALS)
• Issues identified by the Maternity and Neonatal Voices Partnership (MNVP) lead
• Findings from the Maternity and Newborn Safety Investigations (MNSI) programme
• Concerns highlighted through the incident management process All complaints, concerns, and feedback are logged into a central tracking system and monitored through to resolution. To ensure quality and compassion in our communication, all complaint responses are reviewed by the quadrumvirate leadership team before being sent. We also offer families the opportunity to meet with us to discuss their concerns in more detail, should they wish to do so. The Trust’s Being Open policy, introduced in September 2019, underpins our approach to transparency. It reflects our ethical responsibility and duty of candour, requiring healthcare professionals and managers to inform patients and families when care has resulted in harm. In 2023, we undertook extensive cultural diagnosis work with Maternity teams to understand the state of the culture and how best to address the issues identified. In 2024, a three phased cultural action plan commenced, overseen by the Chair of Culture, Inclusion and Organisational Development and the Head of Midwifery. Phase one delivered actions against several themes including:
1. Leadership and Governance
2. Well-being
3. Respect and Civility
4. Psychological safety
5. Leadership Development Increasing leadership visibility and access to leadership colleagues was central to the improvements, with a focus on improving two-way communication with colleagues and setting standards. A lead Professional Midwifery Advocate (PMA) has been appointed with the objective of expanding formal and structured support and education. A number of colleagues have attended training aimed at increasing cultural understanding and

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communication skills between team members. Increased visibility of the FTSU team and processes and engagement in PSIRF training has also been central to the cultural plan. Phase one of the plan is complete.

Actions taken after the inquest: Immediate changes were made to the Being Open policy following evidence given at the inquest. An audit was completed that looked at all complaints that had been converted to incidents to ensure the correct processes had been followed and that the individuals concerned had received appropriate responses. We acknowledged that poor handover of maternity events and concerns to level 3 centres would impact on their decisions around reporting to the CQC and the Coroner and so have enhanced our engagement with these centres. A response to and ’s 1 June 2020 complaint was sent on 24 April
2025.

What we are going to do next: Await the outcome of the Department of Health and Social Care (DHSC) review of the statutory duty of candour for health and social care providers in England. This review aims to assess how the duty is being implemented, monitored, and enforced, and to determine if the policy and its design are appropriate. Once the review is published, we will develop an action plan to address any identified gaps in our processes. Phase two of the Maternity cultural action plan is commencing with increased focus on teamwork, communication and creating psychologically safe teams. Organisationally, a key area of focus is to 'create the culture and conditions for success'. This includes creating a sense of belonging and psychological safety in teams so that they are able to speak up when things are not right. Key enablers for delivering this cultural shift are our FTSU service and strategy and our newly implemented People Strategy which sets out the People Strategy deal - outlining what we expect of colleagues and what they can expect of the Trust. The Deal is aligned to NHS People Promise elements, including 'we each have a voice that counts' and 'we are compassionate and inclusive'. Additionally, it sets out our expectations of teams and a two-way dialogue on flexibility, best practice and strengthening team dynamics, with the aim of creating a productive and high performing team environment focused upon patient experience and care.

As part of the 2025/26 internal audit programme, the Board has asked our internal auditors to complete a review of the implementation of the changes proposed following receipt of the PFD in quarter 4.

B: Clinical Governance and Maternity Governance We fully acknowledge the failings in our clinical governance arrangements that have been identified, including poor version control, absence of document audit trails, disorganised governance structures and an inappropriate tone of self-congratulation in the face of serious incidents. The Trust accepts that it did not undertake a robust examination of its own clinical governance processes in relation to Ida’s death. This is a source of deep regret.

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We recognise the validity of ’s observation at the inquest - that a narrow focus on process over outcomes led to investigations that may have met procedural requirements yet failed to deliver real learning or improve the experience of patients and families. This approach was wholly inadequate and does not reflect the standard of care and transparency that patients deserve. We are committed to ongoing external oversight and transparent engagement with patients, families, and regulators to ensure changes are sustained and effective. We apologise to those affected by our failings and reaffirm our determination to ensure that the lessons learned lead to lasting change. Actions taken prior to the inquest: In 2021, the Trust recognised that there were complex challenges in the organisation that required additional capacity and capabilities. Due to ongoing challenges, the Trust asked to be entered into the national Recovery Support Programme (RSP) in 2021. As part of the RSP, the Trust has been working with NHS England’s Maternity Safety Support Programme (MSSP) since August 2021 and programme leaders have recognised the organisation for improving the maternity service. They have acknowledged and confirmed the measures taken to embed maternity care that is, and feels, safe and effective for women and their families. We progressed to the sustainability phase of the programme in 2024 and await a further assurance visit in the next few months. The Trust engaged the services of the internal auditors (MIAA) in 2024 to assess the effectiveness of governance processes in the implementation and reporting of the MSSP programme. The auditors concluded that there was a substantial level of assurance that the programme was well implemented, with a good system of internal control designed to meet the system objectives, and that controls were generally being applied consistently. There were two recommendations, one relating to action sign off (medium risk) and one relating to a single point of accountability being identified for actions (low risk); both recommendations were implemented immediately and have been signed off by the internal auditors as complete. We have undertaken a comprehensive reform of our Trust-wide clinical governance framework. This includes:
• Strengthening document control and audit mechanisms
• Mandatory training for all staff involved in incident investigation and governance
• Restructuring governance oversight to ensure clarity, accountability, and timeliness
• Shifting the organisational focus from process compliance to outcome-driven learning and meaningful improvement
• Embedding a culture of openness, humility, and family-centred care across all services

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Staff The role induction process for colleagues was not consistent and there was a significant lack of support, direction, correction and education from senior leaders at the time. Concerns around the incident review were not shared with the appropriate colleagues in the organisation. At the inquest, colleagues openly declared that there were several errors of judgement and that they wholly regretted how they had managed the incident. They also apologised to the family. When responding to the HSIB report, a lack of understanding led to the recording of disputes from the clinicians involved in ’s and Ida’s care as well as the factual accuracy comments. This response was sent to HSIB without internal challenge and included the disputes. The response was submitted to HSIB with the approval of the Governance Business Partner and the knowledge of the Head of Midwifery. In view of the inexperience of colleagues in these matters, it would have been a reasonable expectation for them to have received careful guidance, support and correction in this situation. We acknowledge the need for further learning and more robust support and mentorship to support development of colleagues moving into leadership roles. Actions taken immediately after the inquest: Our Director of Midwifery has taken HR advice and concluded that given: 
• The time elapsed from the event 
• The disclosures and insights given at the inquest 
• That the key senior leadership members no longer work for the Trust 

there is nothing further that would be gained from an investigation. The Trust has therefore opted to follow a restorative justice pathway that is bespoke to the individuals. Such pathways may include:
• A skills analysis against the role descriptions
• Individual learning and development plans
• Requirement to provide a reflective statement including key learning points from the matters concerned with ’s and ’s care following Ida’s death
• An emotional and psychological support plan
• Ongoing support through a professional coach

What we are going to do next: Our Director of Midwifery has developed a skills analysis framework, which will be undertaken with all existing midwives who hold senior positions and with all newly-appointed senior midwives. This skills analysis will be referred to at the annual performance appraisal and will inform the continuous learning and development plan for each individual.

Westmorland General Hospital Burton Road

Kendal

LA9 7RG

INTERIM CHAIR:

Tel: 01539 732288

CHIEF EXECUTIVE:

The Board has asked the internal auditors to:
• review the embeddedness of the Kirkup recommendations or their successor practices.
• provide assurance that the governance arrangements in the three divisions are operating in line with the Trust’s Quality Governance Accountability and Performance Accountability Frameworks.
• evaluate the operating effectiveness of controls and level of consistency in place for the management, recording, monitoring and reporting of Serious incidents following the adoption of PSIRF. C: Mandatory Training, expired training and remedial training During the course of the inquest, it became clear that the midwife providing primary care to had not completed every element of her mandatory education. Some elements of the K2 fetal monitoring package had been completed, but not the full package. K2 is an interactive online, e-learning package which offers modules in fetal monitoring and maternity crisis management. All fetal monitoring modules required completion for the staff member to be fully compliant with the K2 training. K2 is no longer in use by the organisation and has been replaced by a fetal monitoring study day, which includes a competency assessment. It also emerged that the senior midwife was, at the time of the inquest, not compliant with the requirement to undertake annual neonatal resuscitation. On hearing this information, the Director of Midwifery immediately issued a direction for this to be rectified within 24 hours. The senior midwife successfully completed her mandatory education the next day. Each year, the Trust must achieve 10 safety standards in order to be eligible for a 10% rebate of contributions to the Clinical Negligence Scheme for Trusts (CNST). Safety action 8 requires Trusts to have a minimum 90% attendance for three elements of training and education:
• Fetal monitoring training 
• Multiprofessional maternity emergencies training (PROMPT) 
• Neonatal life support training 

The Trust has consistently demonstrated 90% compliance for all three areas.  Previously mandatory education has been considered a personal professional responsibility. However, the fetal monitoring guideline published in 2023 states that any clinician who is not compliant with fetal monitoring will have restrictions placed on their practice until relevant training is completed. Actions taken prior to the inquest: The Director of Midwifery commenced a body of work before the inquest concluded which has involved: 
• A weekly compliance report 

Westmorland General Hospital Burton Road

Kendal

LA9 7RG

INTERIM CHAIR:

Tel: 01539 732288

CHIEF EXECUTIVE:

• Personal contact with all clinicians not compliant to remind them of their obligations and agree a plan 
• Provision of a plan and timeframe for all clinicians whose compliance had lapsed 
• Work with the obstetric education lead to include obstetric medical compliance as well as midwifery compliance  
• A requirement for mandatory education to be included in individual annual performance appraisals  
• An analysis of mandatory education compliance is now reported to the Board for oversight at the highest level

What we are going to do next: Map all critical training requirements for clinical areas and ensure compliance across the Trust. Where there are areas of concern, provide training and development to improve skills, knowledge and behaviours. D: Grading of harm for incident reporting: Babies who have sustained hypoxic brain injury and undergo cooling We acknowledge that the grading of harm of the incident should have been reviewed and updated to severe once the severity of the hypoxic injury was known. As part of our refreshed Governance processes, we introduced a daily triage of incidents (see also p3). This is attended by members of the Divisional leadership teams, Corporate Clinical Governance team and Chief Nursing Officer team. This daily triage is accountable to the Executive Review Group (ERG). The function of the daily triage is to triangulate events captured through a variety of routes (i.e. incidents, complaints etc.) and agree the most appropriate learning response based on the Trust’s Patient Safety Incident Response Plan (PSIRP) which includes the potential for learning, improvement and systemic risk.  Any incident that is graded as moderate harm or above triggers the Patient Safety Incident Response Framework (PSIRF) incident management response - this ensures that a comprehensive independent investigation is undertaken. The Trust has also introduced local maternity PSIRF priorities, since there is a lack of national guidance about the response when an incident falls outside the national reporting structure for MNSI and Perinatal Mortality Review Tool (PMRT). We have triangulated data from complaints, moderate and serious harm incidents to develop our local priorities. Neonatal seizures not meeting cooling criteria is one of those priorities. Any incident that meets the local priorities criteria is escalated for executive oversight of the incident management process. The ERG is chaired by the Chief Medical Officer or Chief Nursing Officer. The group is convened twice weekly to oversee all incidents reviewed by the Divisions that have been validated as causing moderate or above harm. In addition to this, the group may review other incidents that trigger organisational concern. The group also reviews all complaints and claims received in the previous week. This process enables executive oversight of any immediate issues which need addressing. The group has the power to investigate any

Westmorland General Hospital Burton Road

Kendal

LA9 7RG

INTERIM CHAIR:

Tel: 01539 732288

CHIEF EXECUTIVE:

clinical or non-clinical activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the ERG. What we are going to do next: We are in the process of employing three full-time Learning Response Leads who will conduct investigations and provide oversight of the PSIRF process. Embed enhanced quality assurance of Patient Safety Incident Investigations through a structured process involving members of the Chief Nursing Officer and Corporate Clinical Governance teams. E: Funding for MSNI Concern not addressed to the Trust. We hope this information is of reassurance but should you require anything further, please do not hesitate to contact us.