A “lethal mix” of problems at a “seriously dysfunctional” maternity unit led to the unnecessary deaths of 11 babies and one mother, an independent inquiry has found.
The investigation of serious incidents at Furness General Hospital in Barrow between 2004 and 2013 uncovered a series of failures “at every level” from the maternity unit to those responsible for regulating and monitoring the trust which runs the unit.
Among those whose lost loved ones at the hospital were former Leyland man Carl Hendrickson, whose wife and newborn baby died at Furness.
The “shocking” problems found in the report, published on Tuesday, included substandard clinical competence, extremely poor working relationships between different staff groups and repeated failure to investigate adverse incidents properly and learn lessons.
Dr Bill Kirkup, who chaired the Morecambe Bay investigation, said his report detailed a “distressing chain of events” which led to avoidable harm to mothers and babies.
He said: “What followed was a pattern of failure to recognise the nature and severity of the problem with, in some cases, denial that any problem existed, and a series of missed opportunities to intervene that involved almost every level of the NHS.
“Had any of those opportunities been taken, the sequence of failures of care and unnecessary deaths could have been broken. As it is, they were still occurring after 2012, eight years after the initial warning event, and over four years after the dysfunctional nature of the unit should have become obvious.”
Dr Kirkup said the origin of the problems lay in the maternity service at Furness General and various factors “comprised a lethal mix that, we have no doubt, led to the unnecessary deaths of mothers and babies”.
The investigation found 20 instances of significant or major failures of care associated with three maternal deaths and the deaths of 16 babies at or shortly after birth.
The Morecambe Bay investigation was launched in September 2013 following a series of deaths of newborn babies and mothers in the maternity and neonatal services unit at Furness General Hospital.
Health Secretary Jeremy Hunt, who ordered the inquiry, said at the time that the principal concern was to find answers for families about what went “desperately wrong” and to ensure there was no repeat.