THE man in charge of an investigation into catastrophic failures of care at a hospital maternity unit has branded progress since his findings became public as 'glacially' slow.

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READ MORE:  Response from University Hospitals of Morecambe Bay NHS Trust

Government patient safety expert Dr Bill Kirkup concluded 11 babies and one mother died as a direct result of a 'lethal mix' of failures at Furness General Hospital between 2004 and 2013.

Now, as the publication of his shocking report nears its first anniversary on Thursday (3), Dr Kirkup has admitted he has been left 'frustrated' by the slow pace of change - before going on to slam the regulatory bodies of the NHS for year long delays.


Dr Bill Kirkup CBE. LINDSEY DICKINGS Dr Kirkup told the Evening Mail: "I can absolutely understand people have got frustrations with the progress made since.

"Progress has indeed been patchy, there are some huge gaps.

"I share in the families frustration in the big national regulators that there have been such long delays.

"It has been unacceptable," he added.

The Morecambe Bay Investigation Report was unveiled at the Grange Hotel, in Grange, on March 3 last year.

The controversial conclusions of Dr Kirkup and his team were that there had been '20 instances of significant or major failures of care' at Barrow's maternity unit leading to the deaths of three mothers and 16 babies.

The deaths of one mother and 11 babies were directly avoidable had they been provided with the correct care, it went on.

The 222 page document found FGH's maternity unit was 'seriously dysfunctional', clinical competence was 'substandard' and a band of 'musketeer midwives' had pursued natural childbirth at any cost.

But Dr Kirkup, who had previously lead an independent investigation into the Hillsborough Disaster, believed the report's comprehensive recommendations would ensure a swift journey towards safer maternity services nationwide.

In an interview with the Evening Mail, however, Dr Kirkup said there are large areas for improvement upon which no progress has been secured whatsover - such as setting up a system of medical examiners to look into hospital deaths, as well as the way complaints are handled within the NHS.

"Progress from the national regulators such as the NMC and the GMC has been terribly unsatisfactory.

"I recognise the level of frustration from the families, to the point that I have offered to broker discussions between them and the trust over delays.

"But I have to say the usual course for the trust would be to defer to the NMC and GMC.

"The trust itself, as far as I can see, seems to have made some noble attempts to deal with difficult problems."

Positive steps towards safer services for pregnant women and babies to spring from the MBR have been forthcoming formation of a National safety Investigation branch to provide aviation-style investigations into clinical incidents.

The National Maternity Review was also published last week providing a blueprint for the way maternity provision could be rolled out across the country within the next five years.

It recommends offering women a birth budget of £3,000 to allow them to commission the birth they want.

The initial reaction to the Morecambe Bay scandal from some quarters was not what Dr Kirkup had hoped for - with a social media backlash against criticism of midwifery practice.

But over the past year, as Dr Kirkup has conducted talks around the country on the tragic events at FGH, the response has been more positive, he claims.

"I think it shocked people initially.

"Subsequently it's been generally accepted though other people may have different perceptions of this and quite rightly.

"At this point, if we are talking about whether we are going in the right direction in terms of safer maternity care I would say yes.

"But are we there yet? No."

Barrow maternity scandal background


THE Morecambe Bay Investigation Report was published last year following an extensive inquiry.

The report found 11 babies and one mother died as a direct result of shocking failures in care at Furness General Hospital's maternity unit between 2004 and 2013.

The tragic death toll was said to have been the result of a 'lethal mix' of factors that included substandard clinical competence and a 'reckless' group of midwives who pursued natural childbirth 'whatever the cost' and were hostile to outside criticism.

It also concluded there had been a cover up reaching through numerous layers of the NHS - with the University Hospitals of Morecambe Bay NHS Trust focussed on achieving foundation status, in order to attract extra funding, over ensuring incidents were investigated and reported.

The Morecambe Bay Investigation was commissioned by the Department of Health in 2013 to establish what had happened within Barrow's maternity unit following a campaign by the families who lost loved ones over the nine year period.

They included Dalton father James Titcombe, whose baby son Joshua died aged just nine days after midwives failed to spot he had a treatable infection in November 2008 and Walney couple Simon and Liza Davey, whose little boy Alex was stillborn on the unit after his birth was mismanaged by midwife Marie Ratcliffe.

The report on the investigation set out a series of recommendations to improve the quality of maternity services both locally and on a national stage.

These include the creation of a safer, fit for purpose maternity unit at Furness General Hospital by December 2017, the retraining of staff and a formal link between the University Hospitals of Morecambe Bay NHS Trust and a teaching trust elsewhere.

Nationally, Dr Kirkup recommended a review of maternity services and a standardised investigation process for the reporting and investigation of maternal and baby deaths, as well as stillbirths.