The Report of the Morecambe Bay Investigation

Dr Bill Kirkup · work from 2013 · published 2015

What this was

Investigation into maternity and neonatal care at Furness General Hospital. It found dysfunctional relationships between midwives, obstetricians and paediatricians, and a failure to investigate deaths properly.

Why it sits in the hub

It led to the national maternity review, Better Births. The same findings — poor teamwork, failure to listen, failure to learn — were then repeated at Shrewsbury, East Kent and Nottingham.

Findings

Finding 1
Substandard care was associated with the deaths of mothers and babies, in a unit whose teams did not function as one.
Culture and conduct Learning from harm Maternity and neonatal care
Finding 2
Families were not listened to, and investigations protected the service rather than establishing what happened.
Candour Listening to patients and families

Recommendations in this hub

Paraphrase of the public recommendations, not the official text.

1AcceptedNHS England
Commission a national review of maternity services.
Better Births followed in 2016.
Maternity and neonatal care
2Partly doneNHS trusts
Investigate deaths and serious harm with a standard that looks for system failure, not a narrative that protects the unit.
Learning from harm Maternity and neonatal care
3Partly doneTrusts and regulators
Refer professional failures to the relevant regulators.
Regulation and oversight