By Cathy Warwick (Royal College of Midwives Chief Executive - click here to visit their site)
I have now had a chance to fully digest Dr Bill Kirkup’s report into Morecambe Bay maternity services. It is a clear and thorough account of the tragic failings in the maternity services at Furness General Hospital over a period of ten years. For many of us this is the first time events have been presented to us so clearly and over such a long time scale. The report is a hard read, but I for one am grateful that it has emerged. There is no doubt that it is the tenacity of a group of deeply affected parents that has resulted in this and I would like to thank them for their courage. The RCM accepts the conclusions and recommendations of the report. All of us connected with maternity services owe the parents and families affected a sincere apology.
I am sure, like me, many of you will be deeply concerned as you read and will feel sad at the many failings identified. We are all here to provide high quality care for women, their babies and their families, and Dr Kirkup’s report makes it abundantly clear that in this case this has not been achieved. There are many lessons to be learned and many recommendations to be taken forward. I hope that every midwife will pay this report attention and have the courage to ask themselves the question ‘Am I sure this could not happen where I work?’ and if the answer to that question is ‘No’ go on to ask themselves what they are doing about it.
The RCM looks forward to being involved in much of this work over the next few months. In particular we must work with others to make it easier for conscientious and caring professionals to speak up when they see failings in care and enable them to be open and honest in all their dealings with families especially when things go wrong.
I am very deeply disturbed at the report’s conclusion that a small number of dominant individuals were pursuing normal birth to an extent which led to inappropriate and unsafe care. This has led to much discussion in the media and on twitter. The RCM will continue to stress in all of our work, that safety is the priority both for women and babies. It is entirely appropriate to support normal birth but the pursuit of this should always be on the basis of appropriate assessment throughout the pathway of care and in consultation with the mother. Actions by midwives should never jeopardise safety. The basis of competent midwifery practice is high quality decision-making based on assessment throughout the care pathway and with appropriate consultation followed by referral and swift and safe transfer should that be necessary. Of course midwives along with their medical colleagues want to reduce unnecessary interventions but necessary interventions can both ensure normality is maintained and be life-saving.
The report’s description of a dysfunctional maternity unit, with poor working relationships is also of grave concern. Whether we are talking about the care of low or high risk women midwives should always be working closely with medical colleagues. Maternity services professionals are a team and, if women are to receive safe care, time has to be put into planning services together, agreeing protocols and indeed into just getting to know each other. High quality teamwork is essential for safe care. This has already been stressed in numerous reports. The RCM and the RCOG work well together at a national level. This must be reflected in every maternity service. Mutual professional respect is critical as a basis for this.
Given my concern at much of what I read , it was comforting to note Dr Kirkup’s acknowledgement that the great majority of staff in the Morecambe Bay Hospitals set out to help patients not to harm them, that there are improvements in staffing (which must be sustained), that recently positive change is happening and that the Head of Midwifery is showing enthusiastic and committed leadership. It is also of some comfort that he acknowledges that the full set of factors coming together to create such a tragedy is likely to be a rarity. However it is as much up to each and every one of us as it is to the managers and regulators to ensure that this is indeed the case. As midwives committed to providing safe care we cannot let this happen again.
As I have said I would very much hope that all midwives will pay close attention to this report. There is no room for complacency. There are lessons for us all.