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WATCH: Dr Bill Kirkup reports on the findings of the independent investigation
A "lethal mix" of failures at a Cumbrian hospital led to the unnecessary deaths of 11 babies and one mother, an inquiry has ruled.
The investigation into Morecambe Bay NHS Foundation Trust found 20 major failures in care from 2004 to 2013 at Furness General Hospital.
It called the avoidable incidents "serious and shocking".
And it criticised the wider NHS for the way it had monitored and regulated the goings on.
In an echo of the inquiries in the Stafford Hospital scandal, the report said the problems found represented a "simultaneous failure of a great many systems at almost every level from labour ward to the headquarters of national bodies".
The investigation - led by Dr Bill Kirkup, a former senior Department of Health official - found:
- The maternity unit was "dysfunctional" with "substandard care" provided by staff who were "deficient in skills and knowledge"
- Working relationships between doctors and midwives were extremely poor with midwives referring to themselves as "the musketeers"
- There was "significant organisational failure" on the part of the Care Quality Commission.
- The North West Health Authority and Parliamentary and Health Services Ombudsman had failed to take opportunities that could have brought the problems to light sooner
- Meanwhile, the Department of Health was reliant on misleadingly optimistic assessments from regulators
Despite the failures starting in 2004 and continuing throughout the period, including a cluster of five major incidents in 2008, it was only in 2011 that the issues at Furness General came to wider attention.
This was after strong criticism from a coroner who looked into the death of newborn Joshua Titcombe. The coroner ruled Joshua had died of natural causes in 2008 but midwives had repeatedly missed opportunities to spot and treat a serious infection.
Around this time a report came to light that the trust itself had commissioned. It was produced in early 2010, but "suppressed" by the trust.
But before that the trust had failed to act on earlier incidents and even distorted the way information was presented to inquests.
Catalogue of errorsThe CQC, regional health authority and ombudsman had not acted properly on what they knew either. There was knowledge of five major incidents in 2009 as the trust had revealed them as part of its application for foundation trust status, which is reserved for elite trusts.
But the regulators did not take the necessary action to fully investigate what had happened and the trust gained foundation status in September 2010.
Dr Kirkup said: "This was a disturbing catalogue of missed opportunities."
His inquiry makes 44 recommendations, including calling for a national review of maternity care and for the General Medical Council and Nursing and Midwifery Council (NMC) to investigate the staff involved in care during the period.
Six midwives are already due before the NMC later this year - and a seventh is being investigated.
Meanwhile, a police investigation into the death of Joshua Titcombe is continuing and the Health and Safety Executive is looking into the case.
Health Secretary Jeremy Hunt is due to make a statement later.
The parents' storyParent power prompted midwife review
James Titcombe's son Joshua was nine days old when he died of sepsis. He was born at Furness General Hospital and was transferred to two other hospitals before dying in Newcastle.
"We asked repeatedly if Joshua should have antibiotics and we were told 'No, he didn't [need any]'," said Mr Titcombe.
"He was wheezing, and he wasn't feeding properly, and my wife called the emergency bell because he was grunting.
"And every time, we were told Joshua was fine and that there was nothing to worry about. At no stage was a doctor ever called."
Afterwards Joshua's progress chart went missing, never to re-emerge, and the coroner later said there was a suspicion that it may have been deliberately destroyed.
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