Content area
Full Text
The report by Dr Bill Kirkup is likely to have major implications for midwifery. Here we look at the potential consequences and the RCM's response.
THE 221-PAGE REPORT of the Morecambe Bay investigation was commissioned following a 'series of failures at almost every level', which ranged from the maternity unit, to those responsible for monitoring and regulating the trust.
It uncovered 20 instances of signifi cant failures and says that there was 'a growing move among midwives to pursue normal childbirth at any costs'.
Th e report was launched in Morecambe, in front of a bank of TV news cameras with an expert panel, including Dr Bill Kirkup, grilled by reporters. Th e majority wanted an answer to one question - 'who is to blame'?
Th e questions were phrased in numerous ways: 'Have those in charge at the trust been fi red?', 'Shouldn't Monitor have taken action?', 'Were the midwives or the doctors responsible?', and 'Whose job was it to stop this?'
But, despite the diff erent lines of enquiry, the answer remained the same: 'We make no criticism of staff for individual errors, which, for the most part, happened despite their best eff orts and are found in all healthcare systems,' repeated Dr Kirkup to reporters.
'What happened at Morecambe Bay required the almost perfect alignment of faults in a large number of systems, from the maternity unit through to health service regulators.'
Although, he added that where individuals colluded in concealing the truth 'their behaviour is inexcusable as well as unprofessional'.
However, blame was not laid on any individual or single aspect of care - but on systematic failures.
Th is point was echoed in the results of the Health and Safety Executive's investigation into events at the trust, which concluded in April, when police confi rmed they did not raise 'any further issues of signifi cance that were not already known to the investigation team', and said that there will be no prosecutions.
Th e RCM has since stated its position and has confi rmed that it will work with all parties and stakeholders in resolving the issues.
Its response states: 'We were shocked when reading the report and we are taking its narrative, conclusions and recommendations with the utmost...