An investigation into baby deaths at Furness general hospital in Barrow between 2004 and 2013 found a “lethal mix” of failings at almost every level.
Set up in 2013 by the then health secretary Jeremy Hunt, the inquiry found maternity services were beset by a culture of denial, collusion and incompetence, and there was an insistence among midwives to pursue normal childbirth “at any cost”.
The problems led to 20 instances of significant or major failures of care at the hospital, associated with three maternal deaths and the deaths of 16 babies at or shortly after birth.
James Titcombe’s son, Joshua, died in 2008 after hospital staff failed to pick up on signs of an infection for almost 24 hours, even after his wife was treated with antibiotics. “Joshua collapsed and had nine days of battling for his life, and then died as a consequence of this infection. It was horrific,” said Titcombe.
He said their efforts to investigate what went wrong were constantly hampered and medical records went missing. “It took a big fight to campaign for an inquiry, which we eventually got a few years later. But I think it missed that opportunity to look at the systemic issues.”
Titcombe said he has been appalled to read of subsequent scandals unearthed at hospital trusts around the country over the past few years and feels that government and health officials failed to learn lessons from what happened at Morecambe Bay.
“Families are just told, ‘Nothing like this has ever happened before, it was a one-off or it’s just one of those things.’ But there are issues across the system, and they’re systemic, and I think this report finally gets that right,” he said. “The warning from history is that these reports are fine, but unless they’re properly implemented, it’s not going to make a difference.”
One of the biggest scandals in NHS history, more than 1,000 families have come forward in a review into maternity cases at Shrewsbury and Telford NHS trust.
The investigation, led by midwifery expert Donna Ockenden, is examining 1,862 serious incidents including hundreds of baby deaths and an unusually high number of maternal deaths, mostly between 2000 and 2018.
An interim review into 250 cases found a major push for natural birth at the hospital, with a caesarean section rate 8-12% below the England average.
West Mercia police has also launched a criminal investigation to establish whether there is enough evidence to bring manslaughter charges against the trust or staff.
Rhiannon Davies said her experience became a “cascade of catastrophic failings” when her baby, Kate Stanton-Davies, died under the trust’s care shortly after she was born in 2009. She said her pregnancy was never risk assessed and when Kate stopped moving “dramatically” during pregnancy concerns were ignored and she was dismissed as having a “lazy baby”.
“But then Kate was born pale, floppy, hypothermic, and there were a series of massive heart decelerations during labour. Everything that should have happened was done wrong, basically,” Davies said. “The midwife panicked and put Kate in the side room and left her to collapse and then failed to resuscitate her.”
Kate was eventually transferred to another hospital via air ambulance but the midwife did not go with her and there were no medical notes. “They didn’t even know her name and I didn’t even get to her before she died,” she said.
Davies welcomed many of the report’s recommendations including the potential benefits of a standard third-trimester scan, increased funding of £200m-350m a year for maternity services and a focus on the difference in outcomes for black, Asian and ethnic minority women.
“If these changes go ahead, they will make a positive difference and they will save baby’s lives,” she said. “And I hope it means other people will get heard much more quickly and their cases looked into appropriately so people are less likely to have to go through what we’ve gone through.”
In June, East Kent hospitals university NHS foundation trust was fined £733,000 in a groundbreaking prosecution by the Care Quality Commission for failures during the birth of Harry Richford, who died seven days after an emergency caesarean section.
Harry suffered a severe lack of oxygen and brain damage during his birth due to a series of mistakes by staff, with his mother, Sarah, saying: “I never imagined that I would feel so helpless, exhausted and distressed lying on an operating table listening to a room full of panicking people who I was relying on to safely deliver Harry.”
The Healthcare Safety Investigation Branch has been investigating the NHS trust since July 2018 after a series of baby deaths and an independent report published in April outlined 24 maternity investigations, including the deaths of three babies and two mothers.
Bill Kirkup, who previously investigated the maternity care scandal at Morecambe Bay, is heading an ongoing government-ordered review of the trust’s maternity services, which is due to report next year.
The latest maternity services scandal is at Nottingham university hospitals trust, where the NHS care watchdog is considering a criminal prosecution over its failure to provide safe care to mothers and babies.
A joint investigation by the Independent and Channel 4 found at least 46 babies have suffered brain damage and 19 have been stillborn at the trust’s maternity units between 2010 and 2020.
An inquest into the death of Wynter Andrews 23 minutes after she was born in 2019 concluded she may have survived if “multiple missed opportunities” were spotted by staff.
Sarah Andrews was admitted to hospital six days after initially suffering contractions and a lack of staffing meant concerns about the pregnancy were missed. Wynter was eventually delivered with the umbilical cord “wrapped tightly around her leg and neck”. The assistant coroner, Laurinda Bower, said: “If [she] had been delivered earlier, it is likely that her death would have been avoided.”