The NHS is launching a review of maternity services in England following a damning report which identified a “lethal mix” of errors that led to the preventable deaths of eleven babies and one mother at a hospital in Cumbria.
The inquiry into the University hospitals of Morecambe Bay NHS Trust found there had been 20 “serious and shocking” failures at Furness General hospital between 2004 and 2013.
Health Secretary Jeremy Hunt declared the tragedy “a second Mid Staffs” and the inquiry criticised the NHS as a whole for how it had regulated and monitored events at the hospital.
The independent report said the many issues found signified a “simultaneous failure of a great many systems at almost every level, from labour ward to the headquarters of national bodies”.
Mr Hunt said the findings “must strengthen our resolve to deliver real and lasting culture change so these mistakes are never repeated.”
He has appointed Dr Mike Durkin, National Director of Patient Safety at NHS England, to implement new guidelines in the reporting of serious incidents and asked NHS England’s Medical Director Sir Bruce Keogh to review current professional codes of conduct for doctors and nurses to make sure that errors are reported, not covered up.
It wasn’t until 2011 that the failures at the hospital came to wider attention, even though they started in 2004 and there were five major incidents in 2008 alone.
Pearse Butler, chair of the Morecambe Bay Trust, said: “The trust has made some very serious mistakes.
“More than that the same mistakes were repeated. For these reasons, on behalf of the trust, I apologise unreservedly to the families concerned. I am deeply sorry that so many people have suffered.”