'Lethal mix' of poor care and dysfunctional relationships led to deaths of 11 babies and one mother

A "lethal mix" of poor clinical care and dysfunctional relationships between doctors and midwives led to the deaths of 11 babies and one mother who would still be alive today if they had been properly looked after.

An independent inquiry into a string of failings at the University Hospitals of Morecambe Bay NHS Trust found there were "significant failures" in a total of 20 cases which may have contributed to to the deaths of two more mothers and five more babies.

The report includes detailed and damning criticisms of the maternity unit at Furness General Hospital in Cumbria, the Trust and the regulatory system.

Dr Bill Kirkup examined 200 cases between 2004 and 2013.

Some involved mothers or babies dying during or just after childbirth.

Other youngsters were left with severe disabilities after being delivered at the hospital.

He outlined a litany of missed opportunities with "major failures at almost every level".

The report makes for heartbreaking reading for the families involved who were praised for their "diligent and courageous" fight for the truth.

Describing the Morecambe Bay Trust as "not fit for purpose", the report's authors criticise staff who "colluded to hide the truth", managers "too focused on winning foundation status for the hospital to notice" and regulators who failed to investigate.

The report found there was a "them and us" culture in the maternity unit, particularly among older midwives characterised as "the musketeers".

It said they failed to pay enough attention to risk and were too focused on achieving "normal childbirth".

"The report charts a distressing chain of events that began with serious failings of clinical care at the maternity unit," the report said.

"What followed was a pattern of failure to recognise the nature and severity of the problem, with, in some cases, denial that any problem existed.

"Had any of those opportunities been taken, the sequence of failures of care and unnecessary deaths could have been prevented."

There was also stark criticism for the regulators whose job it is to protect patients from harm.

The Care Quality Commission, Monitor and the Parliamentary Ombudsman had a "flawed" complaints system where each organisation believed the others were investigating, the report said.

It said the NHS complaints system had "failed relatives at almost every turn" and called for a fundamental review.

"Our findings are stark and catalogue a series of failings at every level - from the maternity unit to those responsible for regulating and monitoring the trust," the report said.

Although the investigation was only tasked at looking at Morecambe Bay it also concluded: "There should be a national review of the provision of maternity care and paediatrics in challenging circumstances, including areas they are rural, difficult to recruit or isolated."

The investigation made 18 recommendations for the Trust and 44 recommendations for the NHS as a whole.