A DAMNING report into the deaths of babies and mothers in the care of University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT) has revealed there was a catalogue of failures at "almost every level".

The investigation covered from January 1, 2004, to June 30, 2013, and in that time highlighted 20 instances of "significant failures of care" in Furness General Hospital's maternity unit.

It said they may have contributed to the deaths of three mothers and 16 babies.

The failures were a result of poor clinical competence, "fractured" relationships between professional groups and the "unacceptable pursuit" of normal childbirth, the report said.

Ordered by Health Secretary Jeremy Hunt in September 2013, the inquiry was chaired by Dr Bill Kirkup, a former deputy chief medical officer at the Department of Health.

Speaking of the failure of care, Dr Kirkup said: "Different clinical care in these cases would have been expected to prevent the death of one mother and 11 babies."

The chair of the investigation concluded what followed was a "disturbing catalogue of missed opportunities" to investigate problems by the trust and subsequently regulatory bodies including the North West Strategic Health Authority, Care Quality Commission, Monitor, the Parliamentary Health Service Ombudsman and the Department of Health.

This included a systematic distortion of the truth within the ward itself.

"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," he added.

The report said the origin of the problems lay in the "seriously dysfunctional nature of the maternity service at FGH".

Dr Kirkup said the factors comprised a "lethal mix" which led to the unnecessary deaths of mothers and babies.

A result of reviewing 15,280 documents from 22 organisations, and 118 interviews with individuals, the report made reference to a number of deaths including those that have been heavily reported in the Gazette previously. 

In a speech in the House of Commons, Mr Hunt apologised on behalf of the Government and NHS and paid tribute to the courage of the affected families.

"There's no greater pain for a parent to lose their child and to do so knowing it was because of mistakes that we now know were covered up makes that even worse," he said.

"The courage of the families in constantly reliving their sadness in a long and bitter search for the truth means that lessons will now be learnt so other families do not have to go through the same nightmare.

"The tragedy we hear about today must strengthen our resolves to deliver real and long-lasting culture changes so that these types of mistakes are never repeated. That is the most important committment we can make to the memories of the 19 mothers and babies who lost their lives."

Barrow and Furness MP John Woodcock said: "The scale of failure levels exposed by this forensic and devastating report is even greater than had been suspected by all but the grieving families who refused to back down in the face of terrible adversity.

"While the overwhelming majority of local hospital staff strive every day for the highest professional and ethical standards, there is no escaping the deeply painful conclusion in Dr Kirkup's report that the hospital we love was compromised by gross failings in care and a deeply inappropriate defensiveness from certain individuals who served at the time.

"Those responsible for the practices laid bare in this document must be held to account - including re-opening of criminal investigations if necessary. Regardless of official sanction, there needs to be an opportunity for families to hear a genuine apology from individual staff members who let them down.

"Dr Kirkup's findings that the maternity unit is now at last performing much better will be reassuring for shocked and worried parents-to-be, but the situation is clearly fragile. It is imperative that his recommendations for change are enacted in full and the government should provide extra support to ensure the necessary change can happen.

"The families who made this report happen have too often been treated as pariahs when in fact their dogged determination will lead to change that will prevent many families suffering future losses similar to those they are still grieving. Their tenacity has saved lives and I want to see them officially honoured by our community.

"The lasting legacy from this terrible episode must be a strong and sustainable maternity unit at Furness General that performs at the highest level, and lasting change in the watchdogs who failed to stop the problems. Nothing can bring back their lost loved ones but the grief and courage of families must lead to lasting improvement."

South Lakes MP Tim Farron said: “The Kirkup review shines a light upon one of the worst episodes of systemic failings within the NHS in recent times. 

"The first issues relating to maternity deaths at Barrow were raised back in 2004. It is awful that it has taken until today to get to the truth of what has happened. Eleven years is simply too long to wait. My thoughts today are with the families who will be reading the report with apprehension and trepidation, hoping words will finally be turned into action. 

"I will continue to do all I can to try and support the families affected and campaign alongside them for the report's recommendations to be enacted. Like them, I want people to be held to account for their actions.”

In an inquest in June 2011, a court heard Joshua Titcombe, the son of James and Hoa Titcombe, of Dalton, died of natural causes on November 5, 2008, at just nine days old.

However the then coroner for South Cumbria Ian Smith said midwives had repeatedly missed opportunities to spot and treat a serious infection.

Mr Smith found a number of failings by UHMBT including poor communication, lack of attendance to Joshua, rushed hospital staff, bad record keeping and an over dependence on guidelines.

He also accused ten staff at FGH of ‘collaborating’ over their statements, to shield each other from criticism after Joshua’s death.

Couple Liza Brady and Simon Davey, of Walney, fought a battle to get an inquest into the death of their son Alex Davey-Brady who was stillborn in September 2008.

An inquest the following year heard the baby was born with the umbilical cord round his neck and had asphyxiated as a result.

Coroner Ian Smith told the court that day he would write a letter to the authority with concerns of the middle-grade doctors plus the monitoring of babies’ heartbeats during the later stages of pregnancy.

Carl Hendrickson’s wife Nittaya died in July 2008 and their son Chester died at FGH the following day.

An inquest into the deaths heard 35-year-old Nittaya suffered an amniotic embolism where amniotic fluid, foetal cells, hair or other debris enters mother’s blood stream and triggers allergic reaction.

Chester, who was delivered by caesarean section, was deprived of oxygen at birth which led to severe brain damage.