By the entrance to Furness General Hospital in Barrow-in-Furness sits a sculpture of a moon with 11 stars. It is a memorial to the mother and babies who died unnecessarily due to poor care at the hospital between 2004 and 2013.
When the memorial was unveiled in 2019, Aaron Cummins who is chief executive at University Hospitals of Morecambe Bay NHS Trust, which runs the hospital, said: "We will never forget what happened. We owe it to those who died to continually improve in everything that we do."
Barely a month later, Sarah Robinson stepped into a birthing pool at the Royal Lancaster Infirmary, a hospital run by the same NHS trust. She was about to give birth to her second child.
Within an hour, Ida Lock was born; within a week, she was dead.
The inquest into Ida Lock's death, which concluded last week, exposed over five weeks why maternity services across England have long struggled to improve - and this one case holds a mirror to issues that appear to be prevalent across a number of trusts.
'That investigation, carried out by Dr Bill Kirkup and published in March 2015, found there had been a dysfunctional culture at Furness General, substandard clinical skills, poor risk assessments and a grossly deficient response to adverse incidents with a repeated failure to properly investigate cases and learn lessons.
Morecambe Bay became a byword for poor maternity care and the trust promised to enact all 18 recommendations from the Kirkup review. And yet that never happened.
Ida Lock's inquest began last month, more than five years after she died - the delay was down to several reasons, including its particular complexity.
What emerged was just how profoundly many of those lessons had not been learned. Particularly egregious, says Ms Robinson, was a suggestion from a midwife – shortly after the birth - that Ida's poor condition was linked to her smoking, something Sarah had never done in her life.
As the coroner found on Friday, Ida's death was wholly avoidable, caused by a failure to recognise that she was in distress prior to her birth, and then a botched resuscitation attempt after she was born.
By the time she was transferred to a higher dependency unit, at the Royal Preston hospital, she had suffered a brain injury from which she could not recover.
Having failed to deliver their daughter safely, Ida's parents would have expected that the trust would properly and openly investigate her death. Instead, they pursued an investigation that Carey Galbraith, the midwife who completed it, would later describe as "not worth the paper it was written on".
They didn't take responsibility for their failings despite having an independent report from the Healthcare Safety Investigation Branch (HSIB).
Clearly, the Morecambe Bay report was not, as was hoped, a line in the sand for maternity services across England, or a rallying cry for widespread improvements. As the inquest has shown, it did not even lead to sustained improvement at Morecambe Bay.
Source: BBC News, 24 March 2025
Further reading:
Recommended Comments
Create an account or sign in to comment