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Failings Uncovered At Baby-Deaths Hospital
An investigation into the deaths of three babies and a mother at a scandal-hit hospital has uncovered serious failings in midwifery care.
The Health Service Ombudsman report also criticised follow-up action taken after the deaths of Joshua Titcombe, Alex Davey-Brady and Nittaya and Chester Hendrickson at Furness General Hospital.
It 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 reviewed the deaths of the three baby boys and Mrs Hendrickson after their families complained about the care given.
The families welcomed the report but said it had taken numerous complaints and requests before an investigation was carried out.
The report said there is a clear "conflict of interest" among midwives working as supervisors, as they are meant to investigate their peers while at the same time being responsible for their support and development.
Dame Julie called for these roles to be separated.
In the case of baby Chester, the report said he died following oxygen deprivation while his mother died shortly after labour.
Two supervisory midwives reviewed the records and "decided that there were no midwifery concerns that would warrant a supervisory investigation", the report said.
But it added: "Midwife A should have identified a number of failings in the midwifery care provided for Mrs M (Mrs Hendrickson), who was a high-risk mother because she had diabetes and was having her labour induced.
"Baby M's heart should have been monitored at regular intervals using continuous foetal heart monitoring from the moment Mrs M arrived in the delivery suite. The fact that this wasn't done should have prompted a decision to investigate."
The report also criticised the local Strategic Health Authority (SHA) for failing to investigate the original decision by the supervisor of midwives not to undertake an investigation.
In the case of Alex Davey-Brady - who was stillborn and referred to as Baby Q in the report - it took seven months for the supervisory midwife to report on what had happened.
"The supervisory investigation should have taken place in 20 days," the report said.
In the case of Joshua Titcombe, whose case is being investigated by Cumbria Police, his mother was given antibiotics because she was unwell but none were given to him.
He was was not seen by a paediatrician until 24 hours later and he went on to die from pneumococcal septicaemia.
The report said the hospital trust had estimated he would have had a 90% chance of survival if given antibiotics earlier.
Dame Julie added: "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."
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