NEWS Morecambe Bay investigation report published


Following concerns over serious incidents in the maternity department at Furness General Hospital (FGH), the Morecambe Bay Investigation report has now been published. Covering January 2004 to June 2013, the report concludes the maternity unit at FGH was dysfunctional and that serious failures of clinical care led to unnecessary deaths of mothers and babies. The Investigation Panel also reviewed pregnancies at other maternity units run by University Hospitals of Morecambe Bay NHS Foundation Trust. It found serious concerns over clinical practice were confined to FGH. The investigation report details 20 instances of significant failures of care in the FGH maternity unit which may have contributed to the deaths of three mothers and 16 babies. Different clinical care in these cases would have been expected to prevent the death of one mother and 11 babies. This is almost four times the frequency of such occurrences at the Trust’s other main maternity unit, at the Royal Lancaster Infirmary. The report says the maternity department at FGH was dysfunctional with serious problems in five main areas: • Clinical competence of a proportion of staff fell significantly below the standard for a safe, effective service. Essential knowledge was lacking, guidelines not followed and warning signs in pregnancy were sometimes


not recognised or acted on appropriately.


• Poor working relationships between midwives, obstetricians and paediatricians. There was a ‘them and us’ culture and poor communication hampered clinical care.


• Midwifery care became strongly influenced by a small number of dominant midwives whose ‘over-zealous’ pursuit of natural childbirth ‘at any cost’ led at times to unsafe care.


• Failures of risk assessment and care planning resulted in inappropriate and unsafe care.


• There was a grossly deficient response from unit clinicians to serious incidents with repeated failure to investigate properly and learn lessons.


The report says proper investigations into serious incidents as far back as 2004 would have raised the alarm. It was not until five serious incidents occurred in 2008 that the reality began to emerge.


Investigation chairman, Dr Bill Kirkup,


said: “There was a disturbing catalogue of missed opportunities, initially and most significantly by the Trust but subsequently involving the North West Strategic Health Authority, the Care Quality Commission, Monitor, the Parliamentary and Health Service Ombudsman and the Department of Health.


“Over the next three years, there were at least seven opportunities to intervene that were missed. The result was that no effective action was taken until the beginning of 2012.” For the Trust, key recommendations include: an apology to families; reviewing skills, training and duties of care; better team working; better risk assessment; an audit of maternity and paediatric services; better joint working across its sites; forging links with a partner Trust; reviewing incident reporting and investigation, complaint handling and clinical leadership; and improving the physical environment of the delivery suite at FGH. The General Medical Council and Nursing and Midwifery Council are recommended to consider investigating the conduct of those involved in patient care. A national review is also recommended of the provision of maternity and paediatric care in rural, isolated or difficult to recruit to areas. Other recommendations call for action


from Trusts, professional regulatory bodies, the Care Quality Commission, Monitor, the Department of Health, NHS England, nursing and midwifery organisations and the Parliamentary and Health Service Ombudsman. The report concludes that significant progress is being made at FGH.


Nanotechnology shows promise for kidney disease care


According to a report by the Institution of Mechanical Engineers, a new medical device which combines nanotechnology with a pregnancy tester could help diagnose and treat the one million people in the UK who do not know they have kidney disease. Developed by engineers in London, the £10 device can be used at home and could revolutionise kidney disease care in the UK, which currently costs the NHS over £1.4 billion – more than breast, lung, colon and skin cancer combined. Created by Bio Nano Consulting, the device


– called quantitative electrochemical lateral flow assay (QELFA) – uses nanoparticles to test the patient’s urine giving results in seconds and is


linked to their surgery via mobile technology so doctors can track how the disease is developing. The Institution’s new report –


Nanotechnology: The Societal Impact of the Invisible – highlights the enormous potential for nanotechnology in our society but calls on the Government to increase funding for nanotech development to ensure the UK does not fall behind other nations. Report author, Dr Helen Meese, head of


materials at the Institution of Mechanical Engineers, said: “Nanotechnology could revolutionise the way we live our lives – it can be used in everything from food and healthcare to electronics, clothing and cosmetics. But despite


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its 40 years in the public domain, the nanotechnology industry is still failing to engage with society in an open and clear way, and governments continue to lack impetus in committing to international regulation. The UK Government must provide more funding to ensure that the UK benefits fully from nanotechnology’s potential.”


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