Maternity Services (Morecambe Bay)

Andy Burnham Excerpts

Tuesday 3rd March 2015 Commons Chamber

[Andy Burnham (Leigh) (Lab)]

I thank the Secretary of State for his well-judged statement, and echo entirely the sentiments he expressed. Families in Barrow and the wider Cumbria area were badly let down by their local hospital and by the NHS as a whole. The Secretary of State was right to apologise to them on behalf of the Government and the NHS, and today I do the same on behalf of the previous Government.

It is hard to imagine what it must be like to lose a child or partner in such circumstances, but to have that suffering intensified by the actions of the NHS is inexcusable. Bereaved families should never again have to fight in the way that these families have had to fight to get answers. The fact that they have found the strength and courage to do so will benefit others in years to come, and I pay tribute to them all, and particularly to James Titcombe.

This report finally gives the families the answers that they should have received many years ago. It explains in detail what went wrong, the appalling scale of the failings and, as the Secretary of State said, the opportunities missed to identify those failings and put them right.

I echo the Secretary of State’s praise for Dr Bill Kirkup, his investigation team and the panel that assisted them. The report’s analysis is thorough, and its recommendations are powerful but proportionate. The Opposition support all the recommendations made today. I understand that the Secretary of State will want to take time to consider each individually, but he can rely on our full support in introducing them at the earliest opportunity.

People’s first concern will be whether local services are safe today. The report identifies the root cause of the failures as a dysfunctional local culture and a failure to follow national clinical guidance. There are suggestions in the report that that culture has not entirely disappeared. The report finds:

“we…heard from some of the long-standing clinicians that relations with midwives had not improved and had possibly deteriorated over the last two to three years…we saw and heard evidence that untoward incidents with worryingly similar features to those seen previously had occurred as recently as mid-2014.”

I am sure the fact that problems have been acknowledged means that there has already been significant improvement, but will the Secretary of State say more about those findings, and about what steps he is taking to ensure that the trust now has the right staff and safety culture?

After safety, people will rightly want accountability, as the Secretary of State said, not just for the care failings, but for the fact that the problem was kept hidden from the regulators and the public for so long. When information came to light, it was not acted on. Lessons were not learned, and problems were not corrected. The investigation recommends that the trust formally apologises to those affected. The whole House will endorse that call, and will want it done both appropriately and immediately. Further, will the Secretary of State ensure that any further referrals to the GMC and NMC are made without delay? Will he also ensure that any managerial or administrative staff found guilty of wrongdoing are subject to appropriate action? A number of staff have left the trust in recent years, many with pay-offs. Will he review those decisions in the light of the report and take whatever steps he can to ensure that those who have failed are not rewarded?

One of the central findings of the investigation is on the challenges faced by geographically remote and isolated communities in providing health services. The investigation warns of the risks of a closed clinical culture in which

“practice can ‘drift’ away from standards and procedures found elsewhere”.

Is not the report right to recommend a national review of maternity care and paediatrics in rural and isolated areas, and will the Secretary of State take that forward? Alongside that, there are concerns about the sustainability of the Cumbrian health economy. My hon. Friend the Member for Copeland (Mr Reed) has today written to the chief executive of NHS England to call for a review of the specific challenges it faces. I hope the Secretary of State will be sympathetic to that call.

On the CQC, the role of the regulator has always been to oppose poor care and challenge practice, but it is clear that it failed in its duty in this case. Given what was known, the decision to register the trust without conditions in April 2010 was inexplicable, as was the decision to award foundation trust status later in 2010, as was the decision to inspect emergency care pathways but not maternity services—in so doing, it failed to act on specific warnings. As the report states, there was and remains confusion in the system over who has overall responsibility for monitoring standards, with overlapping regulatory responsibilities. The Opposition support moves to make the CQC more independent, but does the Secretary of State agree that the journey of improvement at the regulator needs to continue, and that there is a need for further reform? Will he ensure that NHS England draws up the recommended protocol on the roles and responsibilities for all parts of the oversight system without delay, and does he agree that the CQC should take prime responsibility?

I want to close by focusing on two proposals that I believe get to the heart of the matter before us. I have thought carefully about how we truly do justice to the families’ campaign and learn the lessons of both this investigation and the Francis report. In my view, the answer is a much more rigorous system of the review of all deaths in the community and in hospitals than currently exists.

First, is the reform of death certification and the introduction of a new system of independent medical examination well overdue? The Kirkup report echoes findings that go back as far as Dame Janet Smith’s inquiry into the Shipman murders, which were repeated recently by Sir Robert Francis in his two reports on Mid Staffordshire. The previous Government legislated for those reforms and made provision for the independent scrutiny by a medical examiner of all deaths that are not referred to a coroner. That has been piloted and proven to be effective. The investigation says that those reforms could have raised concerns at Morecambe Bay before they eventually became evident.

The second point is that we need a better system for scrutinising deaths in hospital. The report recommends mandatory reporting and investigation of serious incidents of all maternal deaths, stillbirths and unexpected neonatal deaths. Is there not a case to go further, including by looking at moving to a mandatory review of case notes for every death in hospital, and at how we can use a standardised system of case note review to support learning and improvement at every trust?

To help to guide the Opposition’s new approach to quality improvement, Professor Nick Black has agreed to advise us and inform the review, which will be concluded by the end of the month. In our view, that reform is much needed, because rather than looking at a sample of deaths to avoid harm, we would look at every single death to learn lessons, which means that every single person matters. Ideally, the review should be cross-party. I hope the Secretary of State feels able to endorse the review I have announced, which will make recommendations that the next Government can act on immediately. Is that not the best way to do justice to the issues that the families have fought to raise, and to ensure that the legacy of their campaign is to ensure that no others go through what they have gone through?

[Mr Hunt]

I thank the right hon. Gentleman for his measured tone. I am sure he is absolutely sincere in wanting to learn from this tragedy. I thank him for his moving words and for his apology. He will understand that there is nervousness among the families because, in the past, when the Government have talked about rooting out poor care, we have been accused of running down the NHS. We have had a different tone today, and I welcome it.

To answer the right hon. Gentleman’s specific points on the quality of care at the hospital currently, the best person and people to make that judgment are the new CQC and chief inspector of hospitals, Professor Sir Mike Richards. He has said that, in his view, the care at the maternity unity in Furness general hospital is good, and indeed safe—it is more than safe; it is good. That should reassure many people who are using the hospital. He is also very clear that there are many, many improvements to make, and his overall rating for the trust is not good. The report highlights many areas that still need to be addressed, but it is important to give that reassurance.

On death certification, I assure the right hon. Gentleman that we fully support that policy. As he knows, it was recommended in January 2005, so it has taken a long time for both Governments to address. We fully support the policy and have had successful trials. We are committed to introducing it as soon as possible and we want to go further. There may be some common ground, because we, too, have been talking to Professor Nick Black about case note reviews. The latest advice I have had is that it would be technically very difficult to review the case notes of all the 250,000 deaths every year in NHS hospitals, because of the resource implications and the doctors’ time it would take. I asked whether it would be possible to do that. I was advised that, if we looked at case notes hospital by hospital, there would be a risk of trusts getting into big disputes about whether or not a death was avoidable. I asked Professor Black to help me to devise a methodology so that we can assess the level of avoidable deaths by hospital trust. We would be the first health economy in the world to do that. I hope we will have his full support as we take that forward.

On the decision to give the trust foundation trust status, the report makes it clear that Ministers were advised that they had no locus to intervene, because the process had already been set in train—the decision had been deferred but not stopped, so they were not able to intervene. It is clear that the level of knowledge in the Department of Health, as in the rest of the system, was wholly inadequate given what was happening in that hospital.

I should like to make one other point, on a comment made by Labour this morning that the report would say that the failings were very localised. In fact, the report says the opposite. I want to read what Dr Kirkup says in the introduction to the report:

“It is vital that the lessons, now plain to see, are learnt and acted upon, not least by other Trusts, which must not believe that ‘it could not happen here’.”

It is important that we take that lesson from the report extremely seriously.

I would like to finish on a note of consensus. I appreciate that it is not always easy for Oppositions to support the Government publicly as they put right policy mistakes that they have inherited, but I think there is one thing where we can make common ground: the need for culture change in the NHS. Policies can be changed over one Parliament, but culture change takes a generation. What the families who have suffered so much want to know more than anything else is that Members on all sides of the House are committed to that, so that we never again go back to the closed ranks and institutional self-defence that piled agony on to their tragedies, and that, once and for all, we all make the commitment that patients will always come first.