An expert in the field of deaths in pregnancy care damaged hospitals for a culture of 'defensivity' and a refusal to accept mistakes was made when things go wrong.
Dr. Bill Kirkup CBE, who led an investigation into the death of 11 babies in Morecambe Bay Hospitals, called for more 'openness and frankness' instead of the tendency to undermine and play incidents even if babies have died.
She spoke in the investigation into the death of Ida Lock who sustained a brain injury due to a lack of oxygen at the Royal Lancaster Infirmary in Lancashire in November 2019.
A coroner in Preston has heard of a series of shortcomings at the time of her birth, including a delay in calling a crash team, midwives who give Baby Ida ineffective CPR and doctors have to crawl under the bed in the tight delivery room.
Ida's mother Sarah Robison, then 38, had been in a birth coil when she prepared for delivery and there were serious delays in evacuating her while the heartbeat of her baby had fallen considerably in the last 15 minutes.
Ida was brought to the Royal Preston Hospital, a tertiary center that offers specialized treatment, but died six days later.
Dr. Kirkup told the research: “A baby who is healthy after 37 weeks should be healthy and go home after 41 weeks.”
Emphasizing one of the problems caused by reporting such incidents, he said that the fact that tertiary centers deal with seriously ill babies, that nobody was the problem to treat how they ended up there.
Sarah Robison and Ryan Lock's Baby Ida was born in Royal Lancaster Infirmary in November 2019
Dr. Bill Kirkup CBE, who led an investigation into the death of 11 babies in Morecambe Bay Hospitals, called for more 'openness and frankness' instead of the tendency to interrogate incidents and play them when babies have died
He was also seriously critical of the university hospitals of Morecambe Bay Trust, who runs the Lancaster -Hospital where, he said, staff was not willing to accept the responsibility for the death of Ida.
A report commissioned by the hospital itself had found little wrong with the care and treatment of the baby and the staff had refused to accept a report of the Healthcare Safety Investigation Branch – now known as the maternity and newborn safety examination.
The HSIB criticized procedures and emphasized failures in the hospital, but the staff continued to believe that they had done nothing wrong.
Dr. Kirkup said: 'They accepted the recommendations, but did not agree with the reasons behind them.
'The HSIB report is the final report. It is not open to dispute, but as an investigation into air accidents is not.
“That was deeply offensive and useless for the family.
'The hospital's own internal studies were of poor quality, superficial and defensive of staff involved in hiding the important learning that should have been from what had happened.
The baby of the Morecambe parents died only seven days later in the Royal Preston Hospital
“Although the desire to protect personnel can be understood, it should never take priority over the duty of the trust against those damaged or responsibility to understand and prevent the causal link.”
Dr. Kirkup is the author of the Kirkup Report, an investigation into UHMBT set up by the then health secretary Jeremy Hunt in 2015 after the death of 11 babies in the Furness Hospital of the Trust.
Asked by coroner Dr. James Adely how he felt that he was now asking questions about the same hospital, he said: 'It is deeply disappointing. There are echoes of the 2015 study in the poor quality and defensive response that probably reflects a deep sitting culture within the organization. '
He tackles the failure of hospitals to check errors correctly, added: 'I am not in favor of punishing people for clinical mistakes. They are a fact, but it is the denial of things that go wrong that leads to families being denied the truth and everyone is denied the opportunity to learn from mistakes.
“Someone once said that punishing staff if something goes wrong is the biggest obstacle to the patient's safety and to deny that something went wrong, just maintains a cover.”
'We still see the same things happening that happened 20 years ago. That is a very sad fact '.
