Patient Safety Watch: Morecambe Bay's broken promises

Good afternoon, and welcome to this fortnight’s edition of the Patient Safety Watch newsletter.

Tragic death highlights lack of learning at Morecambe Bay

I’ll be totally honest and start by saying that this has easily been the hardest newsletter I’ve had to write so far. Last week saw the conclusion of an inquest into the tragic death of baby Ida Lock, who was born at the Royal Lancaster Infirmary, part of the Morecambe Bay Trust, in November 2019. She suffered a serious brain injury due to a lack of oxygen around the time of her delivery.

As reported by The Independent, at the conclusion of an inquest into Ida’s death last week, HM senior coroner for Lancashire Dr James Adeley, stated: “Ida was a normal child whose death was caused by a lack of oxygen during her delivery that occurred due to the gross failure of the three midwives attending her to provide basic medical care to deliver Ida urgently when it was apparent she was in distress.”

He added: “Ida’s death and subsequent investigation is a damning indictment of an ineffective, dysfunctional and callous system that has failed this family at every opportunity presented to it.”

Following the inquest, the coroner wrote a Prevention of Future Deaths letter to the secretary of state for health and social care, stating: “The trust’s lack of compliance with clinical governance requirements in the investigation into Ida’s death had significant similarities with the criticisms made in 2015 of the trust, as set out in The Report of the Morecambe Bay Investigation…” 

My view?

Having fought hard for the Morecambe Bay investigation after the tragic death of my son Joshua in 2008, it is heartbreaking to know that just four years after the report was published, another family has been devastated by unsafe maternity care at the same trust. One of the key messages from the Morecambe Bay investigation was that whilst mistakes and errors will happen (sometimes with tragic consequences), openness, honesty, candour and learning are non-negotiable.

If any trust in the country should have been getting its response to avoidable harm in maternity services right in 2019, when Ida was born, it should have been Morecambe Bay. Yet the inquest into Ida’s death has highlighted not only a series of avoidable failures in Ida’s care but a gross failure to do what should have been non-negotiable and routine – respond with candour, honesty, compassion and learning.

I agree with Dr Kirkup’s words when he gave evidence at the inquest: this would be “bad enough” in any hospital but it is “unforgivable” in the same trust. Put simply, the promises to learn from the Morecambe Bay investigation and the babies that lost their lives, including Joshua, have not been kept. Some further personal reflections here, but the learning from this case goes beyond Morecambe Bay.

This powerful piece from Michael Buchanan reflects not just on Ida’s tragic case but the worrying picture for maternity safety nationally. There is now an important and ongoing debate about the next steps for maternity safety. Many harmed families are calling for a nationwide inquiry, while others – including Dr Kirkup – argue that what is needed more urgently is: “…a national plan to improve maternity care”.

Patient Safety Watch chair Jeremy Hunt set out some thoughts on what needs to happen to turn around maternity services in The Guardian earlier this week.

Health secretary Wes Streeting has said that maternity care keeps him up at night. The decision as to what happens next rests with him – but the case for change can neither be any clearer nor made any louder. Action must follow.

In other patient safety news this edition…

Landmark victory for hospital whistleblower

In a groundbreaking tribunal ruling, Max McLean, former chair of Bradford Royal Infirmary, has won the right to whistleblower protection. Dr McLean raised concerns about preventable newborn deaths, confirmed by an independent report, but claimed he was forced out by the hospital’s board. When he sought to challenge the trust at an employment tribunal, they argued he wasn’t a worker and was thus unprotected under whistleblowing laws. The tribunal disagreed, declaring him a worker with legal protections.

This decision, reported by Channel 4 News, could reshape accountability across England’s trust boards, empowering members to speak out without fear of retaliation. Dr McLean, a former police officer, told Channel 4: “There is no freedom to speak up. It is a sham.”

The trust declined to comment amid ongoing legal proceedings.

Repeated errors reading scans harming patients, says watchdog

The Parliamentary and Health Service Ombudsman has this fortnight said it has upheld or partly upheld more than 40 complaints across the last four years where similar mistakes in reading scans played a role.

In one of the cases the PHSO investigated, an 82-year-old man’s bowel cancer was diagnosed after multiple visits to the emergency department. The watchdog found clinicians had missed a small lesion on a scan, leading to a six-week delay in surgery and significant pain for the patient. The man eventually ended his life, leaving a note stating he could no longer live with the pain.

PHSO Rebecca Hilsenrath said: “Each of the cases we have investigated and upheld represent a real person whose life has been impacted by failings in care. They are also all instances where the organisations involved failed to identify that anything had gone wrong.”

UKHSA investigates deaths linked to listeria in desserts

BBC News has reported that the UK Health Security Agency is investigating three deaths and two non-fatal cases believed to have been caused by a listeria outbreak linked to desserts provided to NHS hospitals.

The bacteria was detected in a line of mousse desserts, although these have not been confirmed as the source of the infections, and the amount detected in the desserts was below the level known to be tolerated by healthy people.

The Food Standards Agency has confirmed the puddings have been removed from the supply chain while the investigation takes place.

Major A&E ‘undoubtedly causing harm’

A review by NHSE’s Getting It Right First Time team – obtained by HSJ under a Freedom of Information Act request – has warned the emergency department at the Royal Sussex County Hospital in Brighton is “undoubtedly causing patient harm and distress to staff” while “infection prevention control [was] almost impossible” due to patient “stacking”.

Sharing some good stuff…

Because it is not all bad news, here are some positive developments in patient safety and some useful resources to highlight.

Supporting patient and family involvement in patient safety investigations

For those passionate about patient engagement, this brilliant paper gives an overview of the “Learn Together” programme and the development of detailed guidance and principles for involving patients and families in patient safety incident investigations.

This work addresses the previously limited empirical evidence on the impact of such involvement and the lack of guidance on meaningful engagement. By co-designing approaches with patients and families, the programme has produced a suite of free resources that will be invaluable to both staff and patients and families.

Safe care for every newborn and every child – World Patient Safety Day 2025

The World Health Organization has revealed that the theme for this year’s World Patient Safety Day on 17 September 2025 will be “patient safety from the start,” with a focus on safe care for every newborn and every child.

This theme highlights the urgent need to protect newborns and children from preventable harm in healthcare settings. The WHO is calling for global action to improve safety in maternal, neonatal, and paediatric care. Read more here.

MHRA introduces Safety Roundup bulletin and redesigned alerts

The Medicines and Healthcare products Regulatory Agency (MHRA) has launched the Safety Roundup, a monthly bulletin summarising the latest safety advice for medicines, medical devices, and healthcare products. This initiative is part of the MHRA’s three-year strategy to enhance safety communications by providing clearer and more accessible information to healthcare professionals.

Safety Roundup includes:

• Drug safety updates

• Device safety information

• National patient safety alerts

• Recalls and medicines notifications

• Letters sent to healthcare professionals

• An MHRA news section highlighting key safety information

Healthcare professionals can subscribe to the MHRA Safety Roundup to stay informed about the latest safety communications and updates from the MHRA here.

HSJ Patient Safety Awards extended!

The deadline for the 15th annual HSJ Patient Safety Awards has been extended to 17 April 2025.

This awards programme is an opportunity for teams to share best practice and learn from peers, as it highlights critical work being done to deliver better and safer care amid times of significant change and long-standing pressures.

To register your intent to join and to view all categories you can enter, visit https://psa.awardsplatform.com.

Countdown to congress

The HSJ Patient Safety Congress 2025 programme is now available!

This year’s two-day programme spans 12 content streams with over 44 sessions. Now in its 18^th year, it is a must-attend event for those at the forefront of improving patient safety.

Come and hear from speakers like Dr Penny Dash (chair, NHSE and co-leading the restructure) to understand more and explore what it’s going to take to continue to deliver safely amidst times of drastic change.

With a growing line-up of excellent speakers, it’s not to be missed!

The preview rate is now live, giving you the chance to secure your tickets at the best price — saving you up to £76 per ticket. Group booking discounts are also available for teams of three or more.

If you would like to discuss attending the congress in further detail, or require more information, please contact James Elliot by email or call +44(0)20 7549 8648.

That’s all for this edition. Please look out for the next edition from Jeremy in two weeks’ time.

In the meantime, thanks for reading, and stay safe.