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Blog on Morecambe Bay (Kirkup) report

Cathy Warwick, RCM chief executive
3 March, 2015

Blog on Morecambe Bay (Kirkup) report

Today saw the publication of the report of the Morecambe Bay investigation, and many of you will have read or seen coverage of its findings.

This is a highly critical report. It highlights serious mistakes that were repeated over a long period of time that had tragic consequences, as well as deep failures in how these mistakes were investigated.

There are many recommendations in the report, including three where the RCM has been asked to lend its expertise, with others, to improve care.

The report recommends that there should be a national review of the provision of maternity care and paediatrics in challenging circumstances, including areas that are rural, difficult to recruit to, or isolated. This should identify, the report says, the requirements to sustain safe services under these conditions. In conjunction, it argues, a national protocol should be drawn up that defines the types of unit required in different settings and the levels of care that it is appropriate to offer in them.

The report states that the educational opportunities afforded by smaller units, particularly in delivering a broad range of care with a high personal level of responsibility, have been insufficiently recognised and exploited. It recommends that a review be carried out of the opportunities and challenges to assist such units in promoting services and the benefits to larger units of linking with them.

Finally, the report expresses concern about the ad hoc nature and variable quality of the numerous external reviews of services that were carried out at the University Hospitals of Morecambe Bay NHS Foundation Trust. It recommends that systematic guidance be drawn up setting out an appropriate framework for external reviews and professional responsibilities in undertaking them.

The report names the RCM as having a role in taking forward all these recommendations, and this is what we will do. We will also take time to reflect on the overall findings of the report to see what other steps we may be able to take to ensure that such tragic events do not happen again.

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