Morecambe Bay Inquiry Action

'Truth and reconciliation'

Evidence of CQC involvement in suppressing serious concerns at Morecambe Bay

Background

In 2008, there were a number of Serious Untoward Incident’s (SUI’s) at the maternity unit at Furness General Hospital (FGH) in Barrow-in-Furness.

One of these incidents related to the death of a nine day old baby, Joshua Titcombe. Baby Joshua's death was referred by his family to the Health Service Ombudsman in the hope that an investigation would be undertaken (the request was refused in February 2010).

MBIA have obtained correspondence between staff at the Ombudsman and the CQC which clearly shows the level of concerns CQC had in 2009. 

(Read the memo)

  • In the memo from Kathryn Hudson (the deputy Ombudsman) relating to a conversation with the regional director of the CQC, Alan Jefferson on 4th September 2009 the following is stated:
  • ‘Mr Jefferson was well aware of this case which he felt provided evidence of systematic failure in maternity services across the Trust, not solely at Barrow Hospital , but in other hospitals as well. The concerns raised are in relation to the operation of the Trust itself.’
  • ‘There are three principal issues, and another associated one, which links to this case. These are; The treatment of Joshua – discontinuity between maternity, obstetric and paediatric services was not just a “bad day” but raised issues about the dynamics of relationships between the services on a regular basis. Mr Jefferson referred to evidence in a tape recording of an interview which identified the risks of services which had no link between them’
  • ‘The problems are wider than Barrow Hospital alone. Relationships between the different sites were poor, with no consistency between the operations of services in the different hospital. This has raised questions about the overall management of the Trust. An associated issue here is that meetings which in most trusts would be multi-disciplinary, were single disciplinary in this Trust, with the consequent loss of working relationships and sharing of information.’
  • ‘Very poor record keeping. Some write ups were not done and other were lost…Great concern remains about how the notes were lost and the governance system around record keeping and transfer. 

The larger question also remains. If this is happening in maternity and children’s services what is happening in the rest of the Trust?

 

Further evidence of the level of concerns the CQC had in relation to serious risks to mothers and babies at Furness General Hospital (FGH) is shown in a letter from Alan Jefferson to a bereaved father in December 2009.

Alan Jefferson letter on December 2009

In this letter Mr Jefferson wrote:

We believe that if future tragedies are to be avoided, the trust needs to be able to evidence a much more integrated approach to care.

In early 2010, Alan Jefferson left the CQC and a new regional director for the North West of England was appointed, Sue McMillan.

Between December 2009 and February 2010, as well as the concerns in maternity services, MBIA have learned that the Dr Foster unit at the Imperial College in London issued two mortality alerts to the trust, showing that deaths from Septicemia were around 50% higher than they should have been.

Mortality Alerts 2009 and 2010

In April 2010, all NHS trusts were required to register with the CQC under a new system of regulation. Despite all the concerns CQC had about Morecambe Bay, on 16th April 2010, Sue McMillan, wrote to Miranda Carter (the assessment officer at Monitor) as follows:

I therefore confirm that the trust is registered without compliance conditions, we are not investigating University Hospitals of Morecambe Bay NHS Trust and no investigation by the CQC is planned.

Letter to Monitor from CQC