Furness General Hospital scandal

Entrance to the maternity ward at Furness General Hospital

The Furness General Hospital scandal involves an ongoing investigation by Cumbria Constabulary and a number of other government and public bodies into the deaths of several mothers and newborn babies during the 2000s at Furness General Hospital in Barrow-in-Furness, Cumbria, England. Cases date back to 2004, with a number of major incidents occurring in 2008. The death of Joshua Titcombe and a suppressed report by the hospital's trust brought the spotlight onto FGH in 2011 when investigations began.^[1] Claims of medical records being intentionally destroyed alongside the discovery of major wrongdoing on behalf of midwives led to threats of closure to the maternity ward.^[2]

The scandal was covered in a 2012 BBC Panorama episode titled 'How Safe is Your Hospital?' alongside the Stafford Hospital scandal. In June 2013, Cumbria Constabulary announced they would only be pursuing the Titcombe case and other complaints would not proceed to a criminal prosecution.^[3] Later in the same month, the British medical community was rocked by allegations that the Care Quality Commission, which took part in investigations, was in fact fully aware of concerns of maternity care at FGH as early as 2008 and gave the hospital a clean bill of health in 2010 having destroyed evidence to the contrary.^[4]

The independently issued Morecambe Bay Investigation Report was published in 2015 stating a 'lethal mix' of 'serious and shocking' failings had lead to the deaths of eleven babies and one mother.^[1] The report recommended a national review of maternity care and thorough investigations of staff members involved by the General Medical Council and Nursing and Midwifery Council.^[1] Numerous investigations have discovered serious failings, corruption and cover-ups on every level, however with investigations continuing no individual has yet to be held accountable for the deaths at FGH. The criminal investigation into the scandal was concluded in April 2015 with no prosecutions.^[5]

Notable cases

Police did not announce the specific number of deaths being investigated, however six known are listed below.^[6] Several families of the victims have revealed that they are suing the University Hospitals of Morecambe Bay NHS Trust, claiming clinical negligence. The claim of Carl Hendrickson (husband and father of Nittaya and Chester Hendrickson respectively) alone is expected to exceed £50,000.^[6]

• Niran Aukhaj collapsed and died in April 2008 also claiming the life of her unborn child. An inquest revealed that FGH failed to monitor her high blood pressure a week earlier.^[7]
• In July 2008, Thai-born Nittaya Hendrickson and her son died at FGH after she suffered an amniotic fluid embolism. Her husband claims records showing her heart rate during the birth have gone missing.^[7]
• In September 2008, Liza Brady's newborn baby died shortly before birth. It was alleged that midwives delayed in delivering him, despite signs of distress.^[7]
• An initial inquest into the death of nine-day-old Joshua Titcombe at FGH revealed the infection that killed him could easily have been treated if noticed by midwives. His parents Hoa and James claim that their pleas for antibiotics to be given to their son were ignored.^[8]

Cumbria Constabulary and CQC investigations

In September 2011, Cumbria Constabulary assigned 15 officers to investigate the deaths of at least four babies and two mothers during 2008 at FGH; it is alleged that midwives at the hospital destroyed medical records to cover up their mistakes.^[7] On 13 September a number of national newspapers reported that race played a role in the hospital's wrongdoings after it was revealed 83% of serious incidents at FGH in 2008 involved ethnic minorities,^[9] while only 2% of Barrow's population as a whole classifies as non-White.^[10] Cumbria Constabulary have however refused to pursue the racial angle of the crime.^[9]

Besides Cumbria Constabulary, a number of other bodies involved in the investigation include health watchdog, the Care Quality Commission and the Nursing and Midwifery Council. A damning report by the CQC threatened to close down the maternity ward at FGH entirely by 21 November 2011 if major changes weren't implemented.^[2] The NMC identified 19 areas requiring urgent improvement, including governance, risk management, collaborative working and leadership.^[11]

In late October 2011 during the height of the investigation, leaked figures revealed that FGH had the worst mortality rate of any hospital in England.^[12] The mortality ratio for the University Hospitals of Morecambe Bay NHS Trust (which also runs hospitals in Lancaster and Kendal) stood at 124, significantly higher than national average.^[13] It is feared up to 16 babies and two mothers died at FGH due to poor care with over 30 separate claims for compensation, despite this Cumbria police narrowed their investigation in 2013 to focus on the death of just one child deciding not to prosecute over all other deaths.^[3]

Care Quality Commission controversy

In August 2012 new CQC chief executive David Behan commissioned a report by management consultants Grant Thornton.^[14] The report examined the CQC's response to complaints about baby and maternal deaths and injuries at Furness General Hospital was instigated by a complaint from a member of the public and "an allegation of a "cover-up" submitted by a whistleblower at CQC."^[15][16] It was published on 19 June 2013.^[17]

Among the findings, the CQC was "accused of quashing an internal review that uncovered weaknesses in its processes" and had allegedly "deleted the review of their failure to act on concerns about University Hospitals of Morecambe Bay NHS Trust." One CQC employee claimed that he was instructed by a senior manager "to destroy his review because it would expose the regulator to public criticism."^[17] The report concluded: "We think that the information contained in the [deleted] report was sufficiently important that the deliberate failure to provide it could properly be characterised as a 'cover-up'."^[18]

In June 2013, following a series of critical reports and facing 30 civil claims for negligence, it was announced that the organisation would be subjected to a public inquiry.^[19] David Prior, who was appointed CQC Chair in February 2013, admitted that the organisation was "not fit for purpose."^[20] Jeremy Hunt, the Secretary of State for Health, issued an official apology in the House of Commons for "the appalling suffering" of the 30 families involved.^[19]

On 20 June 2013, Behan and Prior agreed to release the names of previously redacted senior managers within the Grant Thornton report, who it is alleged had suppressed the internal CQC report. The people named were: former CQC Chief Executive Cynthia Bower; deputy CEO Jill Finney; media manager Anna Jefferson; who were all said by Grant Thornton to be present at a meeting where deletion of a critical report was allegedly discussed. Bower and Jefferson immediately denied being involved in a cover-up.^[21] In a later interview with The Independent, Bower accused the CQC of commissioning the Grant Thornton report that was neither fair nor reasonable and “against natural justice”, but admitted that the CQC inspection whilst she was CEO had failed to uncover failings at Morecambe Bay trust: "We should have registered it with conditions."^[22] Finney brought an action for libel against the Commission denying that she had been part of a cover-up. The Commission agreed in an out-of-court settlement to pay her £60,000 in damages and £510,000 towards her legal fees. ^[23]

Morecambe Bay Investigation

The Morecambe Bay Investigation Report was the independent public inquiry conducted by Bill Kirkup on behalf of the government into maternity and neonatal services and care at FGH between a wider window of 2004 to 2013. It was published in March 2015 with a damning verdict.^[1] The report stated the deaths of eleven babies and one mother at FGH were completely avoidable and a result of a 'lethal mix' of failings.^[1] Amongst the main findings were that the maternity unit had been 'dysfunctional' with 'substandard care' provided by staff 'deficient in skills and knowledge', working relationships between doctors and midwives had been extremely poor, there had been 'significant organisational failure' on behalf of the Care Quality Commission and the North West Health Authority and Parliamentary and Health Services Ombudsman had failed to take opportunities that could have brought the problems to light sooner.^[1] The report also stated that the Department of Health had been reliant on misleadingly optimistic assessments from regulators. 44 recommendations were made in the report ranging from action to be taken on midwives involved to national reviews on maternity care.^[1]

Improvements

In November 2011 with investigations continuing, the University Hospitals of Morecambe Bay NHS Trust announced plans to replace outdated equipment and completely rebuild FGH's maternity ward at a cost of £5 million.^[24] A random inspection in September 2012 by the CQC found that recommended changes had been made and found quality and safety standards being met.^[25]

See also

• Criticisms and controversies of the CQC

External links

• Morecambe Bay Investigation: Report

References