When will we ever learn?
On March 3, Dr Bill Kirkup published his report on the failures in maternity care at Furness General Hospital (FGH) between 2004 and 2013 (Eyes passim ad nauseum). It received scant media attention, possibly because repeated serious NHS failings have lost their ability to shock. The investigation found 20 instances of significant or major failures of care at the hospital which could have contributed to the deaths of 3 mothers and 16 babies. The report concluded that one mother and 11 babies could have been prevented from dying if they had been given different clinical care.
The report found serious failures at every level of the NHS from the trust to the Care Quality Commission (CQC), Monitor, the Department of Health and the Parliamentary and Health Service Ombudsman (PHSO). Kirkup uncovered a ‘lethal mix’ of factors that led not just to avoidable deaths but a culture where midwives at FGH and the trust itself to cover up what happened. Unsurprisingly, the lessons from previous deaths went unlearned and the harm repeated itself. The report found that following serious incidents there had been ‘instances of distortion of the truth’, ‘distortion of the process underlying an inquest’ and a ‘significant and regrettable attempt to conceal an evident truth, that a cardinal sign of infection in a newborn baby was wrongly ignored’. Most patients and parents will forgive a human error made under pressure, but they will never forgive being lied to, and the harm being covered up such that others are harmed too.
Most damning however is that the PHSO, Dame Julie Mellor, considered these very concerns and published her findings last year. She concluded “I have found no evidence that the Trust, when preparing for the inquest, failed to comply with the law or act in accordance with established good practice. I have seen no evidence that the Trust’s solicitor acted inappropriately, and no evidence that the midwives colluded to present ‘false evidence’ about their knowledge of the implications of a low temperature in a baby. In short, I have found no evidence of maladministration.” How can Mellor have got is so wrong? Mellor’s predecessor Ann Abraham also declined to investigate the death of baby Joshua Titcombe (an early victim of FGH) when the case was referred to her back in 2009. She then took no steps to ensure the issues were followed up by others in the system. As at Bristol, Mid Staffs and elsewhere, had it not been for courageous and determined truth seeking relatives, the harm would have remained concealed.
Kirkup concludes that ‘…the PHSO failed to take opportunities that could have brought the problems to light sooner…’ The Ombudsman’s role is to investigate complaints from those who have received poor care in the NHS in England. It would be hard to imagine poorer care than that which lead to the avoidable deaths of 11 babies and one mother in a single hospital department. Clearly the PHSO, and the culture, organization and resources supporting her, are not fit for purpose. Will she hold herself to account?
Health secretary Jeremy Hunt set out ‘immediate actions’ in response to Kirkup. NHS England medical director Bruce Keogh will to review the professional codes of “both doctors and nurses and to ensure that the right incentives are in place to prevent people covering up instead of reporting and learning from mistakes”. His team will include the GMC, which took 41 months to investigate a complaint by MD about lead consultant paediatrician Dr David Elliman, who was alleged to have failed to act on the serious concerns of Baby Peter whistleblower Dr Kim Holt and others. Why it took nearly three and a half years to close the case with no further action is omitted from the case examiners’ reasoning.
Hunt’s pledge to consider an independent medical investigation team to go in quickly when serious concerns are raised would have amused Dr Bill Pickering. Pickering died in February, but first advocated such an inspectorate in 1998, to swiftly and fairly investigate all serious clinical complaints and whistleblowing concerns (Eye November 1999, February 2000). MD remains a keen supporter, but will not hold his breath. In February 2014, Keogh ordered a ‘review’ into serious allegations of poor care at Bristol Royal Hospital for Children. 13 months later, most of the core group of parents who met Keogh in February 2014 have not yet received confirmed dates to meet inquiry chair Eleanor Grey. Any lessons that could have been learned will be long since lost in the mists of time. The NHS and its regulators are wilfully blind. They don’t do proper, timely, thorough and fair investigations to uncover and prevent patient harm. Until they do, patients will continue to be avoidably harmed.