Following the publication of the Kirkup report, I was pleased to be asked to write a piece for the summer edition of the RCM magazine which was published recently. The full content of the magazine can be accessed online here.
I would not have agreed to do this had I known just how unbalanced the rest of the coverage of the Kirkup report in the magazine was going to be.
The scene is set straight away by the RCM CEO Cathy Warwick on page 5. Cathy refers to the issue of the ‘normality agenda’ and asks ‘are we pushing this too far?’, Cathy’s response is ‘no’.
This response really does amaze me, not least because Cathy doesn’t refer to any study or evidence to support her answer. In this piece, the RCM President Lesley Page even questions the Kirkup report’s clear conclusion that the over zealous pursuit of normal childbirth was a significant factor in what happened at Furness General.
“I searched carefully to find out what was the basis of this emphasis but couldn’t find much.”
I challenge anyone to read the Kirkup report in full and fail to find ample, unequivocal evidence that an inappropriate pursuit of natural childbirth was a major factor in what happened at FGH.
The magazine’s coverage of the Kirkup report continues on page 52. The thrust of this article appears to be to persuade the reader that the actions and behaviour of individual staff at the unit was not a significant factor in what happened and to promote the notion that what happened at FGH was due to an isolated set of systemic failures.
The article quotes the report stating ‘What happened at Morecambe Bay required the almost perfect alignment of faults in a large number of systems from the maternity unit through to health service regulators’.
Dr Kirkup’s report did indeed say this but the context of the comment is very much about the entire sequence of events that spanned from 2004 to 2013 (at least), whereby serious issues went unaddressed for so long. It was not in my view, a comment intended to imply that elements of the kind of problems at Morecambe Bay are unlikely to exist elsewhere. In fact the Kirkup report clearly states that other trusts ‘must not believe that it could not happen here’, a comment that was not included in the article.
The article also states that ‘blame was not laid on any individual or single aspect of care – but on systemic failures’. The piece quotes the Kirkup report stating ‘We make no criticism of staff for individual errors, which for the most part happened despite their best efforts and are found in all healthcare systems’, then goes on to say that this point was echoed ‘in the results of the Health and Safety Executive’s investigation into events at the trust, which concluded in April.’
I’m afraid that this is extremely misleading. The Health and Safety Executive (HSE) have not carried out any kind of investigation into events at the trust. Their consideration of the issues led to the HSE concluding that the circumstances that occurred fell outside the HSE’s policy framework for investigation. The Francis report looked at this issue and concluded that there was a ‘regulatory gap’ and recommendations were made in response.
It is simply not true to assert that the Kirkup report found that blame for what happened rested solely on ‘systemic failures’. In my view, the RCM’s article presents a very selective and biased view of what happened.
In reality, the behaviour and actions of individual staff contributed heavily to the events that occurred.
Some of the findings and conclusions of the report which were not mentioned in the article are as follows:
“Many of the reactions of maternity unit staff at this stage were shaped by denial that there was a problem, their rejection of criticism of them that they felt was unjustified (and which, on occasion, turned to hostility) and a strong group mentality amongst midwives characterised as ‘the musketeers’. We found clear evidence of distortion of the truth in responses to investigation, including particularly the supposed universal lack of knowledge of the significance of hypothermia in a newborn baby, and in this context events such as the disappearance of records, although capable of innocent explanation, concerned us. We also found evidence of inappropriate distortion of the process of preparation for an inquest, with circulation of what we could only describe as ‘model answers’. Central to this was the conflict of roles of one individual who inappropriately combined the functions of senior midwife, maternity risk manager, supervisor of midwives and staff representative.”
“The failure to present a complete picture of how the maternity unit was operating was a missed opportunity that delayed both recognition and resolution of the problems and put further women and babies at risk.”
“There were failures, by both maternity unit staff and senior Trust staff, to escalate clear concerns that posed a threat to safety. There were repeated failures to be honest and open with patients, relatives and others raising concerns.”
“Investigations were almost always unidisciplinary, and were often carried out by the same senior midwife. Many reports that we saw were extremely brief, failed to identify key failures of care, and showed evidence of adopting an inappropriately protective approach to midwives.”
“We were particularly concerned at the conflicts of interest surrounding the position of maternity risk manager, who was also a supervisor of midwives: we believe that she was part of the close-knit midwifery group of ‘musketeers’ and, as a former Royal College of Midwives union official had continued to act in a staff representative role supporting individual midwives.”
“… the strong view amongst staff that they were being unfairly criticised on occasions became overt hostility to those challenging this view. This underlying feeling was evident at times from the approach taken by interviewees in responding to our questions, and was sometimes apparent in email correspondence. The most notable example is an email from one midwife to another concerning a Nursing and Midwifery Council (NMC) investigation that was entitled “NMC Shit”. There is no excuse for committing such views to the record, but more important is the underlying attitude it illustrates”
“…we believe that this strong desire to protect the group led to instances of distortion of the truth. The strongest evidence of this relates to the failure to recognise the significance of Joshua Titcombe’s low temperature and to act on it. Any clinically qualified member of staff looking after neonates should be aware that a failure to maintain temperature is a cardinal sign of infection in a neonate, and Joshua was under observation for potential infection following his mother’s illness and spontaneous rupture of the membranes. The account subsequently given by every midwife involved, including to the inquest into Joshua’s death, was that none of them knew that hypothermia in a neonate could signify infection or should have resulted in an urgent paediatric assessment… This represents a significant and regrettable attempt to conceal an evident truth, that a cardinal sign of infection in a newborn baby was wrongly ignored.”
“It is clear that staff in the maternity unit at FGH failed to follow the duty of openness and honesty. There are reasons that may help to account for why this should be, in light of the pressure of scrutiny on the unit set out above, but that in no way excuses their failure to maintain the standards expected of all NHS staff and of registered professionals.”
“Seen within the context that some staff were prepared to compromise the professional standards expected of them and to conceal the truth, there were other disquieting events surrounding some of the untoward incidents that we looked at that raise concern, including the disappearance of key clinical records and the delayed completion of critical notes.”
If I needed to make this point any stronger, the NMC have recently concluded the first Fitness to Practice hearing for a midwife involved in events at the trust. The panel found that the actions of Marie Radcliffe directly contributed to two avoidable deaths.
“The panel said Ratcliffe’s failings were numerous and involved 14 patients and 68 proven charges. It accepted Ratcliffe had demonstrated some remorse in her letter but felt she had sought to distance herself from her own culpability. She had demonstrated an uncaring and unsympathetic approach to patients and a cavalier way of monitoring the vitals of patients and unborn babies. The panel is of the view that it is this attitude that underpinned her failings.”
Sadly, this latest coverage in the RCM’s magazine suggests that the RCM are still failing to acknowledge the reality of what happened at Morecambe Bay. Perhaps this is to be expected given the history of the RCM’s involvement. For example, in 2011 (two years before the serious failures at the unit at FGH would finally start to be addressed), the RCM’s response to the news that Cumbria Police were investigating the trust was to provide union support and representation for staff. It is worth reflecting that the advice to many of the staff from their legal representation was to refuse to comment during the interviews, an approach that can only have served to hamper the Police’s efforts to establish the truth and cause further distress to families hoping for answers as to why their loved ones died.
It is also not surprising that the RCM are so keen to rebut any suggestion that an over zealous pursuit of normality contributed to the events at FGH given the RCM’s ‘Normal Birth Campaign’, which it heavily promoted during the time period in question and which I firmly believe, was an influencing factor in what happened at FGH.