Review incident investigation structures

[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).

The Thirlwall Inquiry has noted action taken in response to this recommendation.

Recommendation 12 regarding the structures and processes of incidents and the involvement of colleagues. The panel would consider this fully met once more recent action plans are complete and subsequent audits over a year show further evidence of sustained improvement - due to be complete by June 2022

In the Department of Health’s report (July 2015), they state that the Trust has:

“With maternity staff, begun to review how investigations into incidents are carried out and started a programme to raise awareness of incident reporting…” (p. 65)