Maternity Services (Morecambe Bay) — House of Commons, 2015-03-03
Topic: Health
Andrew Murray Burnham (Labour, Centre-left): I thank the Secretary of State for his well-judged statement, and echo entirely the sentiments he expressed. Families in Barrow and the wider Cumbria area were badly let down by their local hospital and by the NHS as a whole. The Secretary of State was right to apologise to them on behalf of the Government and the NHS, and today I do the same on behalf of the previous Government It is hard to imagine what it must be like to lose a child or partner in such circumstances, but to have that suffering intensified by the actions of the NHS is inexcusable. Bereaved families should never again have to fight in the way that these families have had to fight to get answers. The fact that they have found the strength and courage to do so will benefit others in years to come, and I pay tribute to them all, and particularly to James Titcombe This report finally gives the families the answers that they should have received many years ago. It explains in detail what went wrong, the appalling scale of the failings and, as the Secretary of State said, the opportunities missed to identify those failings and put them right I echo the Secretary of State’s praise for Dr Bill Kirkup, his investigation team and the panel that assisted them. The report’s analysis is thorough, and its recommendations are powerful but proportionate. The Opposition support all the recommendations made today. I understand that the Secretary of State will want to take time to consider each individually, but he can rely on our full support in introducing them at the earliest opportunity People’s first concern will be whether local services are safe today. The report identifies the root cause of the failures as a dysfunctional local culture and a failure to follow national clinical guidance. There are suggestions in the report that that culture has not entirely disappeared. The report finds: "we…heard from some of the long-standing clinicians that relations with midwives had not improved and had possibly deteriorated over the last two to three years…we saw and heard evidence that untoward incidents with worryingly similar features to those seen previously had occurred as recently as mid-2014." I am sure the fact that problems have been acknowledged means that there has already been significant improvement, but will the Secretary of State say more about those findings, and about what steps he is taking to ensure that the trust now has the right staff and safety culture After safety, people will rightly want accountability, as the Secretary of State said, not just for the care failings, but for the fact that the problem was kept hidden from the regulators and the public for so long. When information came to light, it was not acted on. Lessons were not learned, and problems were not corrected. The investigation recommends that the trust formally apologises to those affected. The whole House will endorse that call, and will want it done both appropriately and immediately. Further, will the Secretary of State ensure that any further referrals to the GMC and NMC are made without delay? Will he also ensure that any managerial or administrative staff found guilty of wrongdoing are subject to appropriate action? A number of staff have left the trust in recent years, many with pay-offs. Will he review those decisions in the light of the report and take whatever steps he can to ensure that those who have failed are not rewarded One of the central findings of the investigation is on the challenges faced by geographically remote and isolated communities in providing health services. The investigation warns of the risks of a closed clinical culture in which "practice can ‘drift’ away from standards and procedures found elsewhere" Is not the report right to recommend a national review of maternity care and paediatrics in rural and isolated areas, and will the Secretary of State take that forward? Alongside that, there are concerns about the sustainability of the Cumbrian health economy. My hon. Friend the Member for Copeland (Mr Reed) has today written to the chief executive of NHS England to call for a review of the specific challenges it faces. I hope the Secretary of State will be sympathetic to that call On the CQC, the role of the regulator has always been to oppose poor care and challenge practice, but it is clear that it failed in its duty in this case. Given what was known, the decision to register the trust without conditions in April 2010 was inexplicable, as was the decision to award foundation trust status later in 2010, as was the decision to inspect emergency care pathways but not maternity services—in so doing, it failed to act on specific warnings. As the report states, there was and remains confusion in the system over who has overall responsibility for monitoring standards, with overlapping regulatory responsibilities. The Opposition support moves to make the CQC more independent, but does the Secretary of State agree that the journey of improvement at the regulator needs to continue, and that there is a need for further reform? Will he ensure that NHS England draws up the recommended protocol on the roles and responsibilities for all parts of the oversight system without delay, and does he agree that the CQC should take prime responsibility I want to close by focusing on two proposals that I believe get to the heart of the matter before us. I have thought carefully about how we truly do justice to the families’ campaign and learn the lessons of both this investigation and the Francis report. In my view, the answer is a much more rigorous system of the review of all deaths in the community and in hospitals than currently exists First, is the reform of death certification and the introduction of a new system of independent medical examination well overdue? The Kirkup report echoes findings that go back as far as Dame Janet Smith’s inquiry into the Shipman murders, which were repeated recently by Sir Robert Francis in his two reports on Mid Staffordshire. The previous Government legislated for those reforms and made provision for the independent scrutiny by a medical examiner of all deaths that are not referred to a coroner. That has been piloted and proven to be effective. The investigation says that those reforms could have raised concerns at Morecambe Bay before they eventually became evident The second point is that we need a better system for scrutinising deaths in hospital. The report recommends mandatory reporting and investigation of serious incidents of all maternal deaths, stillbirths and unexpected neonatal deaths. Is there not a case to go further, including by looking at moving to a mandatory review of case notes for every death in hospital, and at how we can use a standardised system of case note review to support learning and improvement at every trust To help to guide the Opposition’s new approach to quality improvement, Professor Nick Black has agreed to advise us and inform the review, which will be concluded by the end of the month. In our view, that reform is much needed, because rather than looking at a sample of deaths to avoid harm, we would look at every single death to learn lessons, which means that every single person matters. Ideally, the review should be cross-party. I hope the Secretary of State feels able to endorse the review I have announced, which will make recommendations that the next Government can act on immediately. Is that not the best way to do justice to the issues that the families have fought to raise, and to ensure that the legacy of their campaign is to ensure that no others go through what they have gone through?