AN investigation into the deaths of three babies and a mother at a scandal-hit hospital has uncovered serious failings in midwifery care and follow-ups into what happened.
Joshua Titcombe, Alex Davey-Brady and Nittaya and Chester Hendrickson all died following mistakes at Furness General Hospital in Cumbria.
A report from the Health Service Ombudsman published today found midwives given the role of supervising their peers concluded there had been no errors despite obvious evidence of mistakes.
The arrangements for supervision – required by law – failed to identify poor midwifery practice at University Hospitals of Morecambe Bay NHS Foundation Trust, which runs the hospital.
Ombudsman Dame Julie Mellor has reviewed the deaths of the three baby boys and Mrs Hendrickson after their families complained about their care.
Today, the families welcomed the report but said it had taken numerous complaints and requests for investigation by the Ombudsman’s office before one had been carried out.
The report said there is a clear “conflict of interest” among midwives working as supervisors and called for both these roles to be separated.
Earlier this year, it emerged 37 families planned to take legal action against the hospital. The cases include nine baby deaths and eight cases of cerebral palsy.
Dame Julie said: “We think that there are real weaknesses in the statutory arrangements for the local supervision of midwives which risk failure to learn from mistakes.
“This cannot be in the interests of mothers and babies, or of midwives, and must change.
“We questioned why the supervision and regulatory arrangements were not the same for midwives as they are for the main medical professions, hence our recommendation that the roles of supervision and professional regulation are separated to avoid the potential for a conflict of interest.”
Jackie Smith, chief executive of the Nursing and Midwifery Council, which sets standards for midwifery supervision, said it would consider the report.
“Women and babies deserve safe and effective care, and the public expects proper oversight of midwifery practice where it is delivered and effective regulation when needed,” she said.