Following a large number of Serious Untoward Incidents in maternity services at FGH in 2008, the Chief Executive (CEO) at the time, Tony Halsall, commissioned an external expert (Dame Pauline Fielding), to carry out a full review of the service. The report was first provided to the Trust in March 2010. This review later became known as 'The Fielding Report'.
A full copy of the final report by Dame Fielding:
Some of the key findings of the Fielding report are:
“It was clear from most of our interviews that team working is dysfunctional..."
- “The legacy of the Serious Untoward Incidents has not helped here – the review team heard that relationships between obstetricians and paediatricians at FGH is improving but there is still much more that needs to be done”.
- “The review team felt that multidisciplinary ward rounds do not take place on the labour ward at FGH”.
- "The hospital facilities are not entirely fit for purpose, particularly with respect to the labour ward environment and the distance of theatres and compare unfavourably with others in the trust".
- “There is also a history of poor relationships between midwifes and neonatal staff.."
- “It became apparent during the course of the interviews that there is little understanding of the concept of clinical governance”.
- “Training opportunities for midwifes are seen to be somewhat problematic with training budgets cut”.
- “It was apparent during most of the interviews that there is a lack of common understanding of the role of the Supervisor at all levels of the organisation."
- “It was evident that the relationship between midwifes and senior managers had been damaged."
- “The trust has found it increasingly difficult to attract and appoint high calibre staff of all types. The staff working at FGH have found conditions to be challenging in the last few years”
- “...the morale of the staff in the maternity service has been badly affected. Relations between different categories of the staff and between management have suffered within an atmosphere which at times may have embodied a “blame culture”.
Report hidden from the regulators and from the public
Despite the fact that the Fielding Report contained such concerning information relating to the safety of maternity services at FGH, the CEO of the Trust, Tony Halsall, kept this report hidden from the regulators and from the public. The report was hidden from the CQC during the critical time when the trust was undergoing registration processes. The report was not shared with Monitor at the time the trust was awarded Foundation Trust status.
In July 2012, the CQC stated 'Had the trust provided us earlier with important information, such as a report it had commissioned into maternity services and details of serious incidents we could have escalated our actions earlier.'.
In February 2012, Tony Halsall stated that the failure to disclose the Fielding report to the regulators was 'an error of judgement'.
However, MBIA have obtained a record of Tony Halsall made during a meeting in May 2010, during which he can clearly be heard reassuring the father of a baby that died at Furness General, that there was "nothing the CQC don’t know about our organisation, or that we have not shared with them completely and openly”.
To hear what Tony Hallsall said in May 2010 (two months after he had received the Fielding report which was hidden from the CQC) click the picture.
How can it be acceptable that information raising serious concerns about the safety of mothers and babies was kept hidden from the regulators and the public for so long?