According to a former Department of Health official, infant deaths at a scandal-hit maternity unit could have been prevented if key recommendations made in the wake of the Harold Shipman murders had been followed.
An inquiry led by Dame Janet Smith following the Shipman murders proposed major changes to the way deaths are recorded, recommending how independent examiners should scrutinise death certificates for suspicious patterns that could indicate poor care.
Dr Bill Kirkup – a former Department of Health associate medical director who investigated 11 baby deaths at Furness General Hospital in Barrow – published a report earlier this year stating that greater scrutiny of death certificates by medical examiners could have saved lives.
“If you look at the deaths that occurred in Morecambe Bay as a result of the problems there that were preventable or avoidable, about half of them happened after they should have been obvious. If we had a proper system of looking at deaths systematically, we could have made that unavoidable at that stage.”
The inquiry into the “lethal mix” of failings that led to 20 incidents of significant care failings including the unnecessary deaths of three mothers and 16 babies at or shortly after birth, said midwives on the “seriously dysfunctional” maternity unit were so cavalier they were nicknamed the ‘musketeers.’
Relationships between doctors and midwives were said to have been extremely poor at the University Hospitals of Morecambe Bay NHS Trust hospital. The inquiry also found that staff who were “deficient in skills and knowledge” provided “inappropriate and unsafe care,” and midwives pursued an “overzealous” pursuit of normal childbirth “at any cost” policy.
Dr Kirkup said it should have been “obvious” there were concerns with the clinical competence of certain staff on the maternity unit much sooner than was realised following the first few tragic baby deaths.
Reforming death certification so that anomalies that cause concern are spotted will help prevent any repeat of what happened with Harold Shipman and identify deaths caused by medical negligence.
It is extremely frustrating that since Dame Janet’s recommendations, the death certification system still hasn’t yet been reformed to include medical examiners. We need the necessary safeguards of a medical examiner scheme put in place across England and Wales as soon as possible to help this kind of gross clinical negligence from occurring again.
There are currently a number of pilot schemes for medical examiners in place on a local level but due to financial constraints, they are yet to be implemented nationally.
The Department of Health said it is committed to death certificate reform.
The Clinical Negligence Solicitors at Slater and Gordon Lawyers help families who have had to deal with devastating birth injuries in a sensitive and supportive manner. If your baby was injured during pregnancy or child birth due to medical negligence call us for a free consultation any time of day on 0800 916 9049 or contact us online.