Ida Lock

Dr James Adeley 
HM Senior Coroner  
Lancashire with Blackburn and Darwen 
Coroner’s Court  
2 Faraday Court 
Faraday Drive  
Preston  
Lancashire  
PR2 9NB  

Co-National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

12 June 2025  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Ida Jean Lock who died 
on 16 November 2019  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  21 
March 2025 concerning the death of Ida Jean Lock on 16 November 2019. In advance 
of responding to the specific concerns raised in your Report, I would like to express 
my deep condolences to Ida’s parents and family. NHS England are keen to assure 
the family and the Coroner that the concerns raised about Ida’s and Sarah’s care have 
been listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report, and I apologise for 
any anguish this delay may have caused to Ida’s parents and wider family. I realise 
that responses to Coroners’ Reports can form part of the important process of family 
coming  to  terms  with  what  has  happened,  and  I  appreciate  this  will  have  been  an 
incredibly difficult time for them. 

Your Report concludes that “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  and  contributed  to  by  the  lead  midwife‘s  wholly 
incompetent failure to provide basic neonatal resuscitation for Ida during the first 3 1/2 
minutes of her life that further contributed to Ida's brain damage from which she died 
on 16 November 2019 at the Royal Preston Hospital neonatal intensive care unit.” 

In  your  Report  you  listed  several  concerns  about  Ida’s  death,  and  listed  the 
organisations you expected to respond to each concern: 

A. 
B. 
C. 
D. 

Culture of Candour (Trust, ICB, DHSC)   
Clinical Governance and Maternity Governance (Trust, ICB and DHSC)  
Mandatory Training, expired training and remedial training (Trust and ICB)  
Grading of harm for incident reporting: Babies who have sustained hypoxic  
brain injury and undergo cooling (Trust, ICB, DHSC, NHSE, Mr Streeting)  

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
  
 E.  Funding for Maternity and Newborn Safety Investigations (MNSI) (DHSC and Mr 

Streeting, NHSE and ICB)  

My  response  therefore  focuses  on  concern  D  and  E.  I  note  that  you  have  also 
addressed this report to University Hospitals Morecombe Bay NHS Foundation Trust 
(UHMBT) and NHS Lancashire and South Cumbria Integrated Care Board (LSC ICB). 
These organisations will address specifics as to the changes being implemented as a 
result of the Report. NHS England’s response to you is also made on behalf of the  
Department  of  Health  and  Social  Care  (DHSC),  and  I  understand  that  they  will  not 
therefore  be  issuing  a  separate  response  to  the  Coroner.  With  DHSC  input,  I  have 
also addressed in this response some of your concerns regarding A and B. 

Grading of Harm  

You concluded that in terms of grading of harm, the Trust graded Ida’s level of harm 
as ‘moderate’, even after Ida’s death, and this grading should have been adjusted to 
‘severe’ as the consultant paediatrician at the time identified Ida had a severe hypoxic 
ischaemic  encephalopathy  when  transferred  to  Royal  Preston  Hospital.  You  also 
reference  the  2024  Learn  from  Patient  Safety  Events  (LFPSE)  guidance  which 
replaced the National Reporting and Learning System (NRLS) and the significant risk 
that if reporting is graded on harm alone, clinical care that resulted in hypoxic brain 
damage during delivery, and which was prevented by therapeutic cooling, would not 
adequately identify the problems that caused the harm during the delivery. Finally, you 
also mention that evidence was given of inconsistency nationally in the application of 
categorisation of harm for babies who sustain hypoxic injury due to fetal bradycardia, 
particularly where cooling has occurred. You confirm that clarification would assist in 
the prevention of further maternity deaths and ensure full and proper investigations 
are carried out. 

At the time of Ida’s birth in 2019, the older patient safety systems of NRLS and the 
Serious  Incident  Framework  (SIF)  were  in  place  in  the  majority  of  Trusts  across 
England.  LFPSE’s  full  implementation  to  Trusts  occurred  in  2024  shortly  after  the 
Patient  Safety  Incident  Response  Framework  (PSIRF)  which  was  introduced  on  a 
transitional basis across NHS Trusts between August 2022 and Autumn 2023.  The 
application of PSIRF principles is mandatory for all health services contracted under 
the NHS Standard Contract. The new system and framework represent a significant 
shift in the way the NHS responds to patient safety incidents and marks a shift towards 
more  compassionate,  learning-focused  approach,  which  is  a  key  part  of  The  NHS 
Patient Safety Strategy.   

The introduction of LFPSE sought to move away from a focus on purely categorical 
fields  and  provide  greater  opportunity  for  organisations  to  review  the  content  of 
narrative description in their  patient safety reporting and explore all aspects of care 
that may contributed to harm. Whilst harm grading is present as an important indicator 
by the reporter, strong governance processes within a Trust should provide multiple 

 
 
 
 
 
 points at which this grading can be challenged and changed by others outside of the 
department.  

To support the new system and framework, NHS England has published guidance on 
recording patient safety events and levels of harm (updated in October 2024) - NHS 
England » Policy guidance on recording patient safety events and levels of harm.  For 
example, severe physical harm is defined as when at least one of the following apply: 

•  permanent harm/permanent alteration of the physiology 
•  needed immediate life-saving clinical intervention 
• 
•  needed or is likely to need additional inpatient care of more than 2 weeks 

is likely to have reduced the patient’s life expectancy 

and/or more than 6 months of further treatment 

•  has, or is likely to have, exacerbated or hastened permanent or long term 

(greater than 6 months) disability, of their existing health conditions 

•  has limited or is likely to limit the patient’s independence for 6 months or 

more. 

If we were to apply the new guidance and new framework from 2024 to the information 
reported at the time of Ida’s birth in 2019, as she required resuscitation immediately 
after  birth,  this  should  have  been  categorised  as  ‘severe  harm’  as  she  required 
“immediate  life-saving  clinical  intervention”.    I  therefore  confirm  that  under  the  new 
framework and reporting system, Ida’s grading of harm would be recorded as ‘severe’.   

As you will be aware,  national maternity investigations were established in 2018 as 
part of the Healthcare Safety Investigation Branch (HSIB).  From October 2023,  this 
is now the Maternity and Newborn Safety Investigations (MNSI) programme hosted by 
the Care Quality Commission (CQC). The criteria for an MNSI investigation in early 
neonatal deaths of term babies (within the first week of life), of any cause, includes: - 

•  Severe brain injury: diagnosed as occurring in the first 7 days of life, when the 
baby—  (i)  was  therapeutically  cooled  (active  cooling  only),  or  (ii)  has  been 
diagnosed with moderate to severe encephalopathy, consisting of altered state 
of consciousness (lethargy, stupor or coma) and at least one of the following: 
(aa)  hypotonia;  (bb)  abnormal  reflexes  including  oculomotor  or  pupillary 
abnormalities; (cc) absent or weak suck; (dd) clinical seizures)  

This means that if similar circumstances to what happened with Ida occurred today, 
an independent investigation by MNSI should be triggered separate to any local Trust 
patient safety investigation or assessment.  

This will  be further supported by the roll-out of the new Maternity Outcomes Signal 
System (MOSS). This system will use Trust Electronic Patient Records to show term 
stillbirths,  neonatal  deaths  up  to  28  days  from  birth  and  term  Hypoxic  Ischaemic 
Encephalopathy  (HIE)  at  grade  2/3  for  all  maternity  providers,  to  be  used  as  a 
signalling  system  for  Trusts  when  there  are  clusters  or  an  increased  number  of 

 
 
 
 
 incidents. MOSS is currently in the pilot phase, but is due to be launched in November 
/ December 2025.  

Funding for Maternity and Newborn Safety Investigations (MNSI) 

You concluded that MSNI is currently hosted by CQC with funding secured for the next 
two years and without assurance that funding will continue beyond 2027, you were 
concerned  that  significant  harm  events  to  mothers  and  babies  and  deaths  such  as 
Ida’s will go unrecorded and lessons that should be learned to prevent future maternal 
and  baby  deaths  would  go  unnoticed,  and  there  will  be  a  risk  of  future  maternity 
deaths.  

NHS England acknowledges the importance of, and rigour required, when undertaking 
these investigations and the specialist skills of the investigators. As you may be aware, 
the  Prime  Minister  recently  announced  his  intention  for  the  abolishment  of  NHS 
England, and a transfer of many of our functions into the DHSC. It is expected that this 
process will be completed within a two-year timeframe. The DHSC have engaged with 
us on the concerns raised in your Report and have advised us to share the following 
with you:  

‘The Government is committed to ensuring that all women and babies receive safe, 
personalised and compassionate care. A key part of this is ensuring we have a strong 
and  robust  approach  to  investigations  which  ensures  both  the  appropriate  level  of 
scrutiny into individual cases and that learning is fed back into the system to prevent 
future harm to mothers and babies. The work of organisations such as the Maternity 
and Newborn Safety Investigations Programme (MNSI) is therefore critical.  

The MNSI programme forms part of a wider maternity investigatory landscape, with 
maternal and perinatal deaths also being investigated by Perinatal Mortality Reviews 
(supported  by  the  Perinatal  Mortality  Review  Tool  (PMRT))  and  the  MBRRACE-UK 
Programme.  MNSI  was  initially  established  for  a  time-limited  period,  with  a  review 
the 
planned 
programme’s existing investigatory scope is fit for purpose.    

improvement  and  assess  whether 

identify  opportunities 

for 

to 

To support this review, the DHSC has commissioned an evaluation of the PMRT and 
MNSI programmes via the National Institute for Health and Care Research (NIHR). 
The  evaluation  is  exploring  whether  MNSI  investigations  and  PMRT  reviews  have 
resulted  in  system-level  quality  improvements  in  maternity  care  and  improved 
outcomes  for  parents  and  families.  Further  detail  on  the  evaluation  can  be  found 
at Maternity Investigations and Review Tools process evaluation (MATREP)  - NIHR 
Funding and Awards. The Department will also take into account other feedback, for 
example from families and from this and other PFD reports.’  

Duty of Candour 

Whilst  you  have  not  asked  NHS  England  to  address  this  matter  of  concern  in  your 
Report,  you  have  indicated  that  a  response  from  DHSC  is  welcome.  DHSC  have 
commissioned a response from NHS England, who confirm: 

 
 As you will  be aware,  the  statutory  duty  of  candour  organisationally  places  a direct 
obligation upon NHS Trusts and all other health and social care providers registered 
with the CQC to be open and honest with patients, service users and their families, 
when a notifiable patient safety incident occurs.  The Government supports the review 
on  the  duty  it  inherited  from  previous  administration  and  will  consider  the  findings, 
published  on  26  November  2024.  The  Government  will  consider  these  findings 
alongside  findings  from  the  ongoing  NHS  manager  regulation  consultation  as  it 
continues  to  develop  policy  on  candour  in  healthcare.  The  Department’s  aim  is  to 
ensure the NHS can better meet the objectives of the statutory duty of candour and 
work  with  patients  as  partners  to  support  a  culture  of  learning  and  continuous 
improvement.   

Maternity Governance  

Whilst you have not asked NHS England to address these matters of concern in your 
Report, you have indicated that a response would be welcome from DHSC.  As this 
response is to incorporate DHSC’s response to your Report as well, I would also like 
to provide some assurances to the Coroner regarding maternity governance following 
engagement with and input from my regional clinical quality colleagues in the North 
West.  

At Trust level  

The  Trust  has  been  receiving  support  from  the  National  Maternity  Safety  Support 
Programme  (MSSP)  and  has  been  part  of  the  MSSP  programme  following  a  Care 
Quality Commission (CQC) inspection of maternity services in 2021.  

In regard to the Trust improvements of maternity services, the MSSP completed a full 
diagnostic  assessment,  which  identified  several  areas  for  improvement  including 
governance, maternity strategy and vision and leadership. Having delivered required 
improvements, the Trust entered a sustainability phase of the MSSP (which aims to 
ensure improvements can be sustained) in October 2023. A reset and review meeting 
was held in May 2025 and it was agreed that assurance visits were required to test 
the sustainability and ensure that changes have been embedded. These assurance 
visits are planned for July 2025, and exiting of the programme will be based on the 
findings of these site visits. With regard to next steps, once the Trust exits the MSSP 
they will enter enhanced oversight and gain support from LSC ICB’s Local Maternity 
and  Neonatal  Systems  (LMNS)  (subject  to  change  based  on  the  current  ICB 
restructure).  The  details  of  the  level  of  support  and  oversight  is  currently  in 
development. 

Internally,  the Trust  have also undertaken  a review  of  maternity governance,  which 
has included the following:  
•  An organisation reconfiguration in July 2024. Maternity, neonatal and gynaecology 
services  have  moved  to  the  Surgical  Care  Group,  to  strengthen  support 
mechanisms. 

 
 
 
 
 
 •  The Director of Midwifery continues to have a direct line to the Chief Nurse and 

will continue to report to the Board.  

•  A  number  of  recent  leadership  changes  within  maternity  have  taken  place  and 

they now have a substantive leadership team. 

•  The  maternity  governance  architecture  has  been  further  strengthened  by  the 
establishment of a Maternity/Neonatal Improvement Group to monitor the MSSP 
improvement  plan.  The  reporting  structure  ensures  the  Trust’s  board  receive 

regular reports and contact with the Director of Midwifery.  

•  Embedding  a  culture  of  openness  and  humility  evidenced 

the 
improvement  in  their  National  Education  and  Training  Survey  results  for  both 
midwifery  and  obstetrics  and  engagement  with  the  national  maternity  score 
survey.  

through 

•  All elements of the improvement journey and exit criteria will be further tested in 
all maternity settings via a MSSP quality visit which is planned over three days in 
July 2025.  

At Regional/National Level  

NHS  England  North  West  (NW),  has  developed  a  Management  of  Patient  Safety 
Incidents Standard Operating Procedure (April 2024), which ensures escalation of the 
maternity incidents of serious concern to the NW Regional Maternity Team.  The ICB 
are responsible for escalating concerns, which are shared directly with the regional 
maternity team. The regional maternity team receive, monitor, and share escalation 
through the regional governance architecture. By extreme exception (s), the significant 
concerns  are  escalated  to  the  National  Chief  Midwifery  Officer  and  the  National 
Obstetric Lead within NHS England. 

In addition, the region has Perinatal Surveillance Group in place, which is attended by 
multi-stakeholder group such as the LMNS and external arm’s length bodies, which 
enables to provides a timely identification and escalation of concerns and subsequent 
action(s).   

Regional escalation of maternity risks and concerns to the NHS England national team 
takes place through the maternity-specific Quality and Performance Committee, and 
into the National Executive Quality Group. Any Trust requiring additional support, such 
as UHMBT, can access a Recovery Support Programme meeting where improvement 
and challenges are discussed, and further support requirements are agreed.  

In March 2023, NHS England also published its Three year delivery plan for maternity 
and neonatal services, setting out how we would make care for babies, women and 
their familiar safer, more personalised and more equitable. An update on the first year 
of  the  plan  was  published  in  May  2024.  The  plan  is  supported  by  the  work  of  the 
Maternity  and  Neonatal  Safety  Improvement  Programme  which  aims  to  reduce  the 
rates of maternal and neonatal deaths, stillbirths and brain injuries that occur during 
or soon after birth by 50% by 2025.  

 
 
 
 
 I would also like to provide further assurances on national NHS England work taking 
place around the Reports to Prevent Future Deaths. All reports received are discussed 
by  the  Regulation  28  Working  Group,  comprising  Regional  Medical  Directors,  and 
other clinical and quality colleagues from across the regions. This ensures that key 
learnings and insights around events, such as the sad death of Ida, are shared across 
the NHS at both a national and regional level and helps us to pay close attention to 
any emerging trends that may require further review and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

Co-National Medical Director  
(Secondary Care)

Your ref:  

Our ref:  

6293705 

AK/CM/SL 

Please contact: 

Email:          

29 July 2025 

Dr J Adeley 
Senior Coroner 
Lancashire & Blackburn with Darwen Coroners 

Sent via email to:  

Dear Dr Adeley 

Level 3, Christ Church Precinct 
County Hall 
Fishergate Hill 
Preston 
PR1 8XB 

Tel: 0300 373 3550 
www.lancashireandsouthcumbria.icb.nhs.uk 

Regulation 28: Report To Prevent Future Deaths – Ida Jean Lock  
Conclusion of inquest 21 March 2025 

Lancashire and South Cumbria Integrated Care Board (LSC ICB) provided a formal response in 
relation the Regulation 28: Report To Prevent Future Deaths for Ida Jean Lock on 14 May 2025. 

Since providing this response we have been made aware that our narrative to the concern 
raised regarding University Hospitals of Morecambe Bay Trusts (UHMBT) lack of examination of 
its own clinical governance processes could be strengthened by accurately reflecting the true 
independence of the LSC ICB Maternity and Neonatal Independent Senior Advocate and also 
the current position of this service. 

I apologise for the lack of true clarity in our response to this independent role and availability of 
the service but believe it is vitally important to ensure that the ICB correctly reflects that the 
Maternity and Neonatal Independent Senior Advocate is truly independent of UHMBT in order to 
maintain the relationships with existing families who are utilising the Maternity and Neonatal 
Independent Senior Advisory service rather than potentially casting doubt. It is also essential 
that expectations on the availability of this service are accurately reflected by the ICB – again I 
apologise that this was not made clear in our initial response to you in May 2025. 

The narrative in the ICB response under section 7 page 5 stated: 

‘Specific to maternity the Trust now has an Independent Senior Advocate, whose role is to 
ensure that the voices of women and families are listened to, heard and acted upon by the 
maternity services. In UHMBT the Advocate provides a report to Trust Quality and Assurance 
Committee which the ICB attend. Particular focus on the effectiveness of the Advocate role will 
continue by the LMNS ensuring there is independent challenge and scrutiny’. 

Whilst it is appreciated that this is an unusual situation, I write in order to understand if the 
revised narrative below, which makes explicitly clear the independence of the Maternity and 
Neonatal Independent Senior Advocate and current availability of the service could be accepted 
and published alongside the ICB initial response for the benefit of our population: 

Chair – 

                         Chief executive (interim) – 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ‘The ICB has a Maternity and Neonatal Independent Senior Advocate, whose role is to ensure 
that the voice of women and families are listened to, heard and acted upon by maternity and 
neonatal services.  To note this pilot service is currently under national evaluation by NHS 
England pending a future decision around the role at a national level.  Within Lancashire and 
South Cumbria currently the service is unable to accept new referrals.  Due to this families 
being supported by the service receive an individualised plan and relevant signposting, 
including to other local advocacy organisations.   

In UHMBT the advocate reports to the Trust Quality and Assurance Committee which the ICB 
attend. Particular focus on the effectiveness of the advocate role will continue by the LMNS 
ensuring that there is independent challenge and scrutiny’. 

I would be grateful for your consideration of this matter and should any clarification or 
information be required please do not hesitate to contact me. 

Yours sincerely 

Acting Medical Director 

Chair – 

                         Chief executive (interim) –

Your ref:  

Our ref:  

Please contact: 

Email:           

14 May 2025 

Dr J Adeley 
Senior Coroner 
Lancashire & Blackburn with Darwen Coroners 

Sent via email to:  

Dear Dr Adeley 

Level 3, Christ Church Precinct 
County Hall 
Fishergate Hill 
Preston 
PR1 8XB 

Tel: 0300 373 3550 
www.lancashireandsouthcumbria.icb.nhs.uk 

Regulation 28: Report To Prevent Future Deaths – Ida Jean Lock  
Conclusion of inquest 21 March 2025 

Thank you for your letter dated 21 March 2025 sent following the conclusion of the inquest 
touching the death of Ida Jean Lock. 

I know that you will share my response with Ida’s parents, and I first want to express my deep 
condolences to them along with a sincere apology for the added distress they have suffered as 
a result of the failure in clinical governance processes within University Hospitals of Morecambe 
Bay Trust. 

NHS Lancashire and South Cumbria Integrated Care Board (ICB) are keen to assure the family 
and the coroner that the concerns raised about the care and clinical governance processes 
have been listened to, carefully reflected on and appropriately actioned. 

Through the Regulation 28 report you have raised a number of matters of concern relating to 
the care that Ida and her mother received and clinical governance processes/practices in 
University Hospitals of Morecambe Bay Trust. This letter is in response to these issues, and I 
will respond to each matter raised separately. 

A: Culture of Candour 

1.  There is not a culture of candour within University Hospitals of Morecambe Bay NHS 

Foundation Trust (Trust) and the impact that this has on safety, learning and 
implementing required changes to prevent deaths. Urgent action is required by the Trust 
to meaningfully embed the Dury of Candour. 

Being open and transparent with our population when something has gone wrong within 
healthcare is a priority nationally, regionally and locally. Measures are in place to monitor 
compliance with Duty of Candour through the NHS Standard Contract however Lancashire and 
South Cumbria Integrated Care Board (LSC ICB) also receive updates from the Trust around 
compliance with Duty of Candour through the Trusts Integrated Performance Report and 
attendance at their internal Quality Assurance Committee.  

Chair – 

                         Chief executive (interim) – 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The ICB has identified that the Trust is currently showing common cause variation with the 
lower compliance attributed to staffing capacity. The capacity issue is being addressed through 
divisional reconfiguration and additional capacity was identified which came into effect on 1 April 
2025. An audit has been undertaken and there is an associated action plan in order to improve 
compliance to ensure every patient/family is served Duty of Candour in a timely and 
compassionate manner. The ICB are committed to ensuring that compliance improves and will 
monitor the effectiveness of the action plan through continued mechanisms including 
attendance at the Trust Quality Assurance Committee providing external challenge and scrutiny. 

2. 

's evidence to the inquest was that a deep-seated and endemic culture within 

the Trust leads to denial and a failure to learn. 

Following the Care Quality Commissions (CQC) Inspection of Maternity Services in 2021, the 
service was entered onto the national Maternity Safety Support Programme (MSSP).  A full 
diagnostic assessment was undertaken by the Maternity Improvement Advisor (MIA) allocated 
to the service which identified several areas for focussed improvement work, including 
governance, culture and leadership.   An associated improvement and sustainability plan has 
been developed, and the oversight and assurance are led by the national MSSP team. The LSC 
ICB Local Maternity and Neonatal System (LMNS) are integral to the oversight and assurance 
work reporting internally within the ICB on progress against this work and are committed to 
ensuring that the Trust are building a culture to ensure learning from all patient safety events 
and near misses.    

In addition, the quadrumvirate completed the Perinatal Culture and Leadership Programme in 
2023/2024; this was a national mandated training programme focused on improving the quality 
and safety of maternity and neonatal care.  Following on from this the SCORE culture survey 
was undertaken with the development of an associated action plan. The service identified five 
themes and are progressing these via a phased approach.  There is 6- monthly reporting to the 
LMNS on the progress against this action plan including any identified challenges.  It is 
acknowledged that since the original survey there has been a change in the perinatal 
quadrumvirate, however the current quadrumvirate have been offered support via the Health 
Innovation Agency to access further training. 

As an organisation the trust has worked with the National Recovery Support Programme (RSP) 
on the Well Led domain and engaged in various programmes of work to improve culture and 
learning including: 

⦁ 
⦁ 
⦁ 
⦁ 
⦁ 
⦁ 
⦁ 
⦁ 
⦁ 
⦁ 

Improvements to the Freedom To Speak Up (FTSU) service  
'Leadership For All' development programme  
Stroke service improvements  
Restorative, Just and Learning Culture implementation  
Organisational development work in Maternity Services  
Refresh of organisational strategy and priorities  
Executive leadership development programme  
Service improvement programmes  
Review of medical staffing  
Embedding kindness project in 2022/23 which informed the Patient Experience strategy. 

Improvements were monitored through a System Wide Improvement Board leading to 
movement from a national System Oversight Framework (SOF) 4 position to SOF 3 and there is 
continued oversight through the System Improvement Assurance Group (IAG). 

Chair – 

                        Chief executive (interim) –

 
 
 
 
 
 
 
 
 
 
 Additionally, the ICB are sighted on the improvements being made to embed the Patient Safety 
Incident Response Framework (PSIRF) which is focused on learning and compassionate 
engagement. We do however acknowledge that progress with PSIRF has been limited which in 
turn delays learning and improvements. In order to address this the ICB are aware that 
additional capacity has now been sought to ensure that investigations into patient safety events 
are conducted in a timely manner, and this is currently being closely monitored with appropriate 
challenge provided to the Trust at both internal Trust and external assurance meetings.  
Within the wider organisation the Trust attend and actively participate in the ICS Shared 
Learning Forum and Patient Safety Specialist meetings. The ICB  will ensure that actions taken 
from these discussions are implemented.   

3.  The Trust's approach to the inquest has been one of a lack of transparency and 

openness, failure to provide relevant information and a failure to identify with candour the 
defective clinical governance processes that have operated at the Trust from 2019 to 
present day. 

The LMNS, (the maternity arm of the Integrated Care Board) has established and embedded a 
governance and reporting structure for all local maternity services.  This includes a bi-monthly 
Quality Assurance Panel and Patient Safety Learning Group (see attached Terms of 
Reference).  UHMBT maternity service are fully engaged and provide regular reporting on 
maternity and neonatal outcomes and patient safety incidents in order to maximise learning 
across the Integrated Care System (ICS). 

The ICS Maternity Patient Safety Learning Group is a dedicated forum to share learning from 
incidents across the system which UHMBT actively participate via their reporting and dedicated 
case discussions. In addition, the LMNS is a member of UHMBT Maternity &Neonatal 
Improvement Group, at this meeting a review of evidence is undertaken against the 
improvement actions in line with MSSP Plan.  Also, the LMNS is invited and attends the 
UHMBT quarterly quality review with MNSI where a review of completed investigations with a 
focus on the identified learning and improvement actions is discussed. 

The ICB is sorry that the family and coroner experienced a lack of transparency and openness 
throughout; this is not the expectation of LSC ICB where we are working hard to implement and 
embed a culture of incident reporting to highlight opportunities for patient safety/experience to 
be improved. Particular attention will be focused with the Trust in ensuring assurance can be 
evidenced going forward.   

4.  The Trust did not disclose that they had failed to notify the external bodies namely the 
CQC and the then CCG [ICB] via StEIS and the Trust's internal Serious Incidents 
Reporting Investigation panel, none of which was noted by the Trust's Patient Safety 
Summits. 

In line with contractual and regulatory requirements LSC ICB expects all providers to report all 
patient safety events onto the Learning From Patient Safety Events (LFPSE) platform (this has 
replaced the National Reporting Learning System – NRLS). Where appropriate and in line with 
Trust local and national priorities, patient safety events must also be reported onto StEIS where 
the ICB is then notified. The ICB is very concerned to note from your findings that the Trust 
failed to fulfil these contractual and regulatory requirements. Since the inception of the ICB 
there has been a detailed oversight in the reporting of patient safety events from the Trust 
against expected reporting, with challenge where there has been unexpected variation. The ICB 
will continue to seek assurance from the Trust through the contractual route and by the ongoing 
scrutiny of patient safety events. 

Chair – 

                          Chief executive (interim) – 

 
 
 
 
 
 
 
 
 Please be re-assured that specifically for maternity services, as part of the LMNS Patient Safety 
Learning Group, UHMBT Maternity service provide a two monthly report on all patient safety 
incidents.  This includes any incidents that have met the national and local priorities of the trust 
PSIRF plan, MNSI investigations, and all other incidents that have had a maternity patient 
safety review.  

It is understood by LSC ICB that Mersey Internal Audit Authority (MIAA) as external auditors are 
scheduled to undertake an audit on the Trust’s PSIRF progress in 2025/26; the ICB will seek a 
copy of the audit outcome and  monitor the implementation of any resulting action plan. 

5.  Trust figures to the Board provided in 2025 stated that there were no complaints over 6 

months old when the Trust at the time of the inquest have not responded to 

 and 

’s 1 June 2020 complaint with the Trust's failure to categorise 

Ida's death as only "Moderate Harm" (see point 4 above) cause me also to have concern 
about the reliability of Trust's data. 

The ICB acknowledges the concerns of the coroner in respect of reliability of data. In order to be 
re-assured on the validity of data either supplied to the ICB or in the public domain, triangulation 
of hard and soft information is undertaken. This also includes the use of a Soft Intelligence 
System across Lancashire and South Cumbria; issues can be raised that allow for consideration 
of further interrogation or collation/theme/trending to build a wider view of a service or provider. 
This system plus all the other information held gives an ability to validate information/data 
provided and where necessary provide external scrunty and challenge through formal contract 
meetings and Quality Review meetings.  

A clinical audit report is presented to the Trust’s Quality Assurance Committee on a quarterly 
basis which includes audits on documentation.  Where audit standards are not being met there 
are mechanisms in place to track actions and re-audit.  The Trust also report on clinical data 
quality as part of their annual quality account and perform well for data accuracy against peers. 
The ICB will continue to use this way of working paying particular attention in the ongoing need 
for triangulation of all data sources. 

B. Clinical Governance and Maternity Governance  

6.  The clinical governance arrangements at the Trust require urgent review to ensure the 

appropriate personnel are in place, with the necessary training and skills to deliver robust 
clinical governance to ensure patient safety in maternity care. 

As previously described the maternity service is on and remain under the remit of the national 
MSSP programme.  Since being on the programme, a full review of governance has been 
completed by MIAA with an associated improvement plan developed.  A focussed project to 
develop and implement a Maternity Quality Governance and Accountability Framework was 
completed in April 2023; the aim of the framework is to ensure that the roles and responsibilities 
of staff are clearly defined within the outlined risk and incident management process.   
The ICB does acknowledge that because of the divisional re-configuration within the Trust 
particular attention will need to be paid by the LMNS to ensure that clinical governance for 
maternity services is not negatively impacted. 

Chair – 

                          Chief executive (interim) – 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 7.  The Trust did not undertake any examination of its own clinical governance processes, 

which were a principal area of concern, and which was identified to the Trust five months 
before the inquest commenced. The deficiencies included lack of version control and 
audit of documents, untrained staff, chaotic clinical governance arrangements, defensive 
attitudes and inappropriate self-congratulation. 

The ICB is deeply saddened that the family of Ida were unnecessarily exposed to an extended 
court hearing as result of poor clinical governance within the Trust; we were very concerned to 
read the findings from the inquest and do not support poor governance practices. We are aware 
that there has been staffing vacancies/absences within the clinical governance team which we 
would partly attribute to the deficiencies identified.  The ICB are assured that key governance 
posts have been recruited to and staff commenced in post (albeit interim in some cases). The 
ICB will continue to monitor the impact of this recruitment to assure itself that clinical 
governance practices are improved, embedded and sustained. Additionally, the ICB will attend 
internal Trust key committee meetings and ensure scrutiny is afforded and challenge given 
where these practices are seen.  

Specific to maternity the Trust now has an Independent Senior Advocate whose role is to 
ensure that the voices of women and families are listened to, heard and acted upon by the 
maternity services. In UHMBT the Advocate provides a report to Trust Quality and Assurance 
Committee which the ICB attend.  Particular focus on the effectiveness of the Advocate role will 
continue by the LMNS ensuring there is independent challenge and scrutiny. 

8.  Specific concerns relating to individual members of staff 

As these concerns are relating to individual staff members the ICB believes that UHMBT are 
best placed to respond to the coroner concerns. 

9.  All investigations conducted by the Trust to date in respect of Ida’s death have been 

unskilled, superficial, brief, failed to identify issues and left the family without answers 
and were all features identified by the 2015 Kirkup Report. In view of the continuing 
culture at the Trust, this cause a significant concern that issues of safety and 
safeguarding are not properly considered, transparently engaged with and then 
addressed formally in respect of a child fatality and serious injury by the Trust. 

As stated earlier in this response the ICB acknowledges that the Trusts journey in implementing 
and embedding PSIRF, the frameworks principles and the training of investigators in line with 
national expectations is not as advanced as initially planned or expected. This includes the clear 
need for compassionate engagement that is timely, open and transparent when care goes 
wrong. We are re-assured by the Trust that there is a plan in place to address these gaps and 
will actively and robustly monitor the progress to fully meet the PSIRF expectations using both 
quantitative and qualitative intelligence sources.  

Additional scrutiny is now provided by the ICB through attendance at internal Trust safety panel 
meetings where learning response reports are shared and discussed as to whether they meet 
the criteria as outlined in the national framework. Constructive challenge is consistently 
delivered by the ICB in a supportive manner in order to assure ourselves that the investigation 
and report are of good quality with particular focus on family/patient engagement and 
involvement in the process.  

Chair – 

                          Chief executive (interim) – 

 
 
 
 
 
 
 
 
 
 
 
 In addition, the LMNS have implemented a system wide Patient Safety Learning Group, in 
which the UHMBT Maternity service provide a two monthly report on all patient safety incidents 
(as described earlier in this response). 

The ICB can confirm that in line with the National Maternity Incentive Scheme the LMNS also 
undertake quarterly quality assurance visits to review evidence against each of 10 safety 
actions. 

10. The Trust now uses the PSIRF model and is to appoint 3 whole time equivalent 

Response Leads by 30 September 2025. However, I remain concerned that the Trust has 
not fully engaged with the duty of candour such that I am not satisfied that the work on 
PSIRF to date has truly addressed the issues in respect of Trust’s investigations. 

The Trust implemented PSIRF in line with national guidelines and within the required timescale 
however the ICB is aware that further progression of this agenda has been delayed due to lack 
of suitably trained investigators. The ICB is required to assure itself on the quality of the 
investigation and the quality of the report; this is done through attendance at the Trust internal 
Learning Response Group where evidence is available of supportive challenge when ICB 
concerns are raised. Particular attention is focused on the transparency of the 
investigation/report and the engagement with the patient/family. The Trust recognise that further 
work is needed to ensure that investigators are trained to use and apply the Systems 
Engineering Initiative for Patient Safety (SEIPS) framework methodology in their investigations 
(or a suitable alternative such as the Yorkshire Contributing Factors Framework). We are 
pleased that the Trust now utilise Patient Safety Partners who are able to offer an independent 
view on patient safety matters, challenging where necessary and are also aware that 

 is providing specific training for staff on compassionate engagement following a 

patient safety event.  

The ICB will continue to scrutinise all patient safety reports, provide supportive challenge to 
ensure the principles of a positive patient safety culture and the PSIRF are fully embedded and 
sustained with the Trust.  

C. Mandatory Training, expired training and remedial training 

11, 12 and 13. The Trust do not have robust systems in place to ensure that any midwife 
who has not completed her mandatory training is subject to immediate action to ensure 
that all mandatory training is completed and is in date. There was no remedial training 
put in place for either the midwives involved in Ida's delivery and resuscitation or for the 
paediatric SHO after Ida’s death. This raises a significant concern that the Trust do not 
operate a system of remedial training when this inquest has identified remedial training 
was required. 

It is acknowledged that whilst the LMNS has oversight and assurance of training in line with 
Training Needs Analysis (Maternity Incentive scheme safety action 8), this does not include 
mandatory training.  The Director of Midwifery at UHMBT has provided reassurance to the 
LMNS that further actions are underway to ensure there is monthly reporting on mandatory 
maternity training with deep dives to understand those staff not compliant and immediate action 
taken to remedy this position. As an LMNS we will seek assurance through the monthly 
reporting process that all staff are compliant and where this is not the case the rationale and 
actions being taken to ensure patient safety. 

Chair – 

                          Chief executive (interim) – 

 
 
 
 
 
 
 
 
 
 
 
 
 D: Grading of harm for incident reporting: Babies who have sustained hypoxic brain 
injury and undergo cooling 

14. The Trust graded Ida’s level of harm as “moderate”, even after her death. This 
grading should have been adjusted to "severe" by the Trust before Ida was 
transferred to Royal Preston Hospital as the consultant paediatrician identified that 
she had sustained a severe hypoxic ischaemic encephalopathy due to foetal 
bradycardia. 

15. There is a significant risk that if reporting is graded on harm alone, clinical care that 
resulted in hypoxic brain damage during delivery and which was prevented by 
therapeutic cooling, will not adequately identify the problems that caused the harm 
during the delivery. 

16. 

 confirmed that nationally there is inconsistency in categorisation of harm for 

babies who sustain a hypoxic injury due to foetal bradycardia in labour and who 
require cooling and clarification guidance would assist prevent further maternity 
deaths and ensure full and proper investigation of hypoxic injuries sustained in 
labour. 

As an ICB and LMNS we are aware that the ongoing challenges in the grading of harm, 
directives from the PSIRF and how this aligns to CQC is a recognised issue both nationally and 
regionally  

The North-West Regional Chief Midwife is developing Maternity Guidance and Principles with 
the aim to ensure there is a consistent approach in the identification and reporting of incidents. 
The ICB are supportive of this work and are actively engaged with the regional work to reduce 
this known risk. 

E. Funding for MSNI  

 17. But for the HSIB investigation report into Ida’s death 
that Ida’s death due to failures by the Trust would never have come to 
light or resulted in an inquest. 

 admitted 

18. The MSNI is now hosted by the CQC with funding secured for the next two years but no   
certainty as to ongoing funding after this date. These independent investigations by 
specialist skilled investigators into the most serious of events is an essential safeguard to 
the lives of mothers and unborn children. 

19. Without an assurance that funding will continue beyond 2027 I am concerned that 
significant harm events to mothers and babies and deaths such as Ida's will go unrecorded 
and lessons that should be learned to prevent future maternal and baby deaths will go 
unnoticed, and there will be a risk of future maternity deaths. 

LSC ICB fully support and acknowledge the important role that MSNI play in undertaking truly 
independent maternity investigations and the value that these investigations have. The funding 
for this service is led nationally and therefore the ICB are unable to offer any assurances on this 
matter. 

Chair – 

                          Chief executive (interim) – 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I am grateful to you for highlighting your concerns to me and I hope that by this letter, I have 
addressed your concerns, but should you require any further clarification or information, please 
do not hesitate to contact me. 

Yours sincerely 

Medical Director (Interim) 

Att: Terms of Reference 

Chair – 

                         Chief executive (interim) –

Trust Headquarters 
Westmorland General Hospital 
Burton Road 
Kendal 
LA9 7RG 

Tel: 01539 732288 
Web: www.uhmb.nhs.uk 

16 May 2025 

Your ref: 

Our ref: 

Dear Dr Adeley 

Re Ida Jean Lock (Deceased) 

Thank you for your Prevention of Future Death Report dated 21 March 2025. 

Firstly, we would like to express our deepest condolences to the parents and family of Ida. 
We want to apologise for the lapses in care that resulted in her tragic death and the further 
harm we then caused by how we handled the investigation. We recognise the distress this 
has caused Ida’s loved ones and are truly sorry for this.  

We have accepted your findings and reviewed our practices, policies and procedures in light 
of these, so that we can identify where further changes need to be made.  We are committed 
to learning from this tragic event and the issues identified during the inquest. 

For ease, our responses to your matters of concern follow under the headings used in your 
report. 

A: Culture of Candour  

Following Ida’s death, the Trust did not follow its own policies. We should have met with 
Ida’s parents at the start of the investigation process. We should have awaited the outcome 
of the Healthcare Safety Investigation Branch (HSIB) investigation. The internal investigation 
relied on flawed and unconventional Root Cause Analysis (RCA) methodology with a narrow 
scope.  This resulted in a failure to identify and address the acts and omissions in care that 
contributed to Ida’s death in the conclusions reached. Once the HSIB report was available, 
the Trust should have accepted the findings in the report unreservedly and considered why 
the conclusions differed from those of the internal investigation.   

We acknowledge with deep regret that the tragic death of Ida and the manner in which we 
investigated the case, demonstrated the serious systemic failures that were present within 
our Trust. It is clear that culture contributed to defensiveness, and a failure to engage in 

Westmorland General Hospital 
Burton Road  
Kendal   
LA9 7RG  
Tel: 01539 732288 

INTERIM CHAIR: 
CHIEF EXECUTIVE: 

 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 meaningful learning from adverse events. This impeded our ability to take timely and 
appropriate action to prevent harm and failed those we were entrusted to care for. 

Specifically, we recognise the unacceptable failure to notify key external bodies—namely the 
Care Quality Commission (CQC) and the then Clinical Commissioning Group (now the 
Integrated Care Board (ICB) via the Strategic Executive Information System (StEIS). This 
omission not only breached statutory reporting duties but also deprived the wider health 
system of critical information necessary for oversight and learning. 

To reinforce a culture of candour within the Trust - where openness, honesty, and learning 
are embedded at all levels - we have implemented a range of measures that go beyond 
compliance and aim to change behaviours, mindsets, and systems. In addition, we continue 
to monitor the impact of these changes through ward to board governance arrangements. 
The changes we have made are detailed below. 

By embedding these measures, the Trust is taking deliberate and sustained action to move 
beyond a culture of defensiveness, towards one of honesty, accountability, and continuous 
learning. These steps are critical in restoring public confidence, supporting staff wellbeing, 
and, most importantly, ensuring safer care for our patients. 

The Duty of Candour process is now embedded across the organisation. The maternity 
service has consistently demonstrated that all women and their families receive duty of 
candour within 10 working days of an incident occurring. This is monitored via the Quality 
Governance Assurance Framework. There is a standardised formal duty of candour letter, 
and communication is regular, with a single point of contact for families to raise any 
questions or concerns.   

The completion of Duty of Candour responses across the wider Trust is monitored via the 
Quality Governance Assurance Framework and reported on at the Quality Assurance 
Committee.  

There has been a pilot project, where families have also been informed about the role of 
the Maternity and Neonatal Senior Independent Advocate (MNSIA), an external point of 
contact who provides support and assists with advocacy. The application of this was 
monitored via the Quality Governance Assurance Framework. This is a national pilot 
programme that has recently closed and we await information around its continuation. 

There was never any intention by the Trust to be lacking in transparency and openness in its 
approach to the inquest. However, it is recognised that issues were identified at the inquest, 
which had not been identified by the Trust’s own investigations, at which point it became 
evident that further information was relevant.  Every effort was made to locate and share this 
information as swiftly as possible, as soon as its relevance was identified. 

Actions taken prior to the inquest:  

Strengthening Freedom to Speak Up (FTSU) 

•  Enhanced visibility and support: The FTSU Guardians and FTSU Champions are 

now more visible and accessible across clinical and non-clinical areas, providing staff 
with safe, confidential pathways to raise concerns. 

Westmorland General Hospital 
Burton Road  
Kendal   
LA9 7RG  
Tel: 01539 732288 

INTERIM CHAIR: 
CHIEF EXECUTIVE: 

 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 •  Leadership responsiveness: Senior leaders regularly engage with FTSU data and 

themes to identify systemic issues and ensure swift action is taken.  

•  The FTSU team reports to the Board of Directors. 
•  Psychological safety training: Dedicated training has been introduced to help leaders 
and teams foster environments where staff feel safe to raise concerns without fear of 
blame or reprisal. 

Daily Triage and Cross-Care Group Reviews 

•  Multi-disciplinary daily triage meetings have been established to review new 
concerns, incidents, and patient feedback in real time. This ensures timely 
recognition of risk, early escalation, and coordinated responses. 

•  These reviews involve cross-care group participation, breaking down silos and 
promoting shared learning, transparency, and consistency in how patient safety 
concerns are addressed. 

•  The daily structure enables tracking of themes and emerging trends, helping to 

identify issues early and prevent escalation. 

Implementation of the Patient Safety Incident Response Framework (PSIRF) 

•  The Trust is actively implementing PSIRF, which marks a fundamental shift in how 

we respond to patient safety incidents. 

•  Focus on learning, not blame: PSIRF prioritises understanding 'what' and 'how' over 

'who', reducing defensiveness and enabling open dialogue. 

•  Flexible, proportionate responses: The framework allows for different types of 

learning responses (e.g. thematic reviews, case note reviews, patient safety incident 
investigations), depending on the nature and impact of the incident. 

•  Co-produced investigations: We are involving patients, families, and staff in shaping 

the terms of reference and contributing to learning outcomes. 

•  Training and capacity building: Staff involved in incident responses are being trained 
under PSIRF principles to ensure quality, compassion, and consistency in approach. 

Cultural Leadership and Accountability 

•  Executive and board-level commitment to candour is now more visible, with regular 

walkarounds, open forums, and leadership-led safety conversations. 

•  Leadership performance reviews include assessment of behaviours that support 

psychological safety, candour, and learning. 

•  Quarterly culture reviews track staff perceptions and feedback, with action plans 

developed in collaboration with teams. 

Promoting a Culture of Transparency and Accountability 

Regular mortality reviews and triangulation meetings reinforce the message that every 
patient outcome matters, and that the organisation is committed to learning, not blame. 
When embedded in organisational culture, these forums: 

•  Foster trust among staff, patients, and families 
•  Support the principles of the Duty of Candour 
•  Promote reflective practice and continuous professional development. 
•  Contribute to better governance oversight and regulatory compliance. 

Westmorland General Hospital 
Burton Road  
Kendal   
LA9 7RG  
Tel: 01539 732288 

INTERIM CHAIR: 
CHIEF EXECUTIVE: 

 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 Enhancing Clinical Governance and Risk Management 

By ensuring that lessons learned from mortality reviews are discussed alongside other 
sources of intelligence, triangulation meetings play a central role in: 

Informing board-level decision-making 

• 
•  Shaping training, staffing, and resourcing priorities 
•  Anticipating risk and preventing future harm 

In 2022, a structured process was implemented to monitor and track complaints within 
maternity services. This includes weekly meetings between the Patient Experience Team 
and maternity service representatives to ensure timely review and action. 

Service user feedback is collected from multiple sources, including: 

•  Formal complaints 
•  Concerns raised with the Patient Advice and Liaison Service (PALS) 
• 
Issues identified by the Maternity and Neonatal Voices Partnership (MNVP) lead 
•  Findings from the Maternity and Newborn Safety Investigations (MNSI) programme 
•  Concerns highlighted through the incident management process 

All complaints, concerns, and feedback are logged into a central tracking system and 
monitored through to resolution. 

To ensure quality and compassion in our communication, all complaint responses are 
reviewed by the quadrumvirate leadership team before being sent. We also offer families the 
opportunity to meet with us to discuss their concerns in more detail, should they wish to do 
so. 

The Trust’s Being Open policy, introduced in September 2019, underpins our approach to 
transparency. It reflects our ethical responsibility and duty of candour, requiring healthcare 
professionals and managers to inform patients and families when care has resulted in harm. 

In 2023, we undertook extensive cultural diagnosis work with Maternity teams to understand 
the state of the culture and how best to address the issues identified. In 2024, a three 
phased cultural action plan commenced, overseen by the Chair of Culture, Inclusion and 
Organisational Development and the Head of Midwifery. Phase one delivered actions 
against several themes including:  

1.  Leadership and Governance 

2.  Well-being 

3.  Respect and Civility 

4.  Psychological safety 

5.  Leadership Development 

Increasing leadership visibility and access to leadership colleagues was central to the 
improvements, with a focus on improving two-way communication with colleagues and 
setting standards. A lead Professional Midwifery Advocate (PMA) has been appointed with 
the objective of expanding formal and structured support and education. A number of 
colleagues have attended training aimed at increasing cultural understanding and 
Westmorland General Hospital 
Burton Road  
Kendal   
LA9 7RG  
Tel: 01539 732288 

INTERIM CHAIR: 
CHIEF EXECUTIVE: 

 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 communication skills between team members. Increased visibility of the FTSU team and 
processes and engagement in PSIRF training has also been central to the cultural plan. 
Phase one of the plan is complete. 

Actions taken after the inquest:  

Immediate changes were made to the Being Open policy following evidence given at the 
inquest.  

An audit was completed that looked at all complaints that had been converted to incidents to 
ensure the correct processes had been followed and that the individuals concerned had 
received appropriate responses.  

We acknowledged that poor handover of maternity events and concerns to level 3 centres 
would impact on their decisions around reporting to the CQC and the Coroner and so have 
enhanced our engagement with these centres.  
A response to 
2025. 

’s 1 June 2020 complaint was sent on 24 April 

 and 

What we are going to do next:  

Await the outcome of the Department of Health and Social Care (DHSC) review of the 
statutory duty of candour for health and social care providers in England. This review aims to 
assess how the duty is being implemented, monitored, and enforced, and to determine if the 
policy and its design are appropriate. Once the review is published, we will develop an action 
plan to address any identified gaps in our processes. 

Phase two of the Maternity cultural action plan is commencing with increased focus on 
teamwork, communication and creating psychologically safe teams.  

Organisationally, a key area of focus is to 'create the culture and conditions for success'. 
This includes creating a sense of belonging and psychological safety in teams so that they 
are able to speak up when things are not right. Key enablers for delivering this cultural shift 
are our FTSU service and strategy and our newly implemented People Strategy which sets 
out the People Strategy deal - outlining what we expect of colleagues and what they can 
expect of the Trust. The Deal is aligned to NHS People Promise elements, including 'we 
each have a voice that counts' and 'we are compassionate and inclusive'. Additionally, it sets 
out our expectations of teams and a two-way dialogue on flexibility, best practice and 
strengthening team dynamics, with the aim of creating a productive and high performing 
team environment focused upon patient experience and care. 

As part of the 2025/26 internal audit programme, the Board has asked our internal auditors 
to complete a review of the implementation of the changes proposed following receipt of the 
PFD in quarter 4. 

B: Clinical Governance and Maternity Governance  

We fully acknowledge the failings in our clinical governance arrangements that have been 
identified, including poor version control, absence of document audit trails, disorganised 
governance structures and an inappropriate tone of self-congratulation in the face of serious 
incidents. The Trust accepts that it did not undertake a robust examination of its own clinical 
governance processes in relation to Ida’s death. This is a source of deep regret. 

Westmorland General Hospital 
Burton Road  
Kendal   
LA9 7RG  
Tel: 01539 732288 

INTERIM CHAIR: 
CHIEF EXECUTIVE: 

 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 We recognise the validity of 
process over outcomes led to investigations that may have met procedural requirements yet 
failed to deliver real learning or improve the experience of patients and families. This 
approach was wholly inadequate and does not reflect the standard of care and transparency 
that patients deserve. 

’s observation at the inquest - that a narrow focus on 

We are committed to ongoing external oversight and transparent engagement with patients, 
families, and regulators to ensure changes are sustained and effective. We apologise to 
those affected by our failings and reaffirm our determination to ensure that the lessons 
learned lead to lasting change. 

Actions taken prior to the inquest: 

In 2021, the Trust recognised that there were complex challenges in the organisation that 
required additional capacity and capabilities. Due to ongoing challenges, the Trust asked to 
be entered into the national Recovery Support Programme (RSP) in 2021.   

As part of the RSP, the Trust has been working with NHS England’s Maternity Safety 
Support Programme (MSSP) since August 2021 and programme leaders have recognised 
the organisation for improving the maternity service. They have acknowledged and 
confirmed the measures taken to embed maternity care that is, and feels, safe and effective 
for women and their families. We progressed to the sustainability phase of the programme in 
2024 and await a further assurance visit in the next few months.   

The Trust engaged the services of the internal auditors (MIAA) in 2024 to assess the 
effectiveness of governance processes in the implementation and reporting of the MSSP 
programme. The auditors concluded that there was a substantial level of assurance that the 
programme was well implemented, with a good system of internal control designed to meet 
the system objectives, and that controls were generally being applied consistently. There 
were two recommendations, one relating to action sign off (medium risk) and one relating to 
a single point of accountability being identified for actions (low risk); both recommendations 
were implemented immediately and have been signed off by the internal auditors as 
complete.  

We have undertaken a comprehensive reform of our Trust-wide clinical governance 
framework. This includes: 

•  Strengthening document control and audit mechanisms 
•  Mandatory training for all staff involved in incident investigation and governance 
•  Restructuring governance oversight to ensure clarity, accountability, and timeliness 
•  Shifting the organisational focus from process compliance to outcome-driven learning 

and meaningful improvement 

•  Embedding a culture of openness, humility, and family-centred care across all 

services  

Westmorland General Hospital 
Burton Road  
Kendal   
LA9 7RG  
Tel: 01539 732288 

INTERIM CHAIR: 
CHIEF EXECUTIVE: 

 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 Staff  

The role induction process for colleagues was not consistent and there was a significant lack 
of support, direction, correction and education from senior leaders at the time. Concerns 
around the incident review were not shared with the appropriate colleagues in the 
organisation.   

At the inquest, colleagues openly declared that there were several errors of judgement and 
that they wholly regretted how they had managed the incident. They also apologised to the 
family.  

When responding to the HSIB report, a lack of understanding led to the recording of disputes 
from the clinicians involved in 

’s and Ida’s care as well as the factual accuracy 

comments. This response was sent to HSIB without internal challenge and included the 
disputes. The response was submitted to HSIB with the approval of the Governance 
Business Partner and the knowledge of the Head of Midwifery. In view of the inexperience of 
colleagues in these matters, it would have been a reasonable expectation for them to have 
received careful guidance, support and correction in this situation.    

We acknowledge the need for further learning and more robust support and mentorship to 
support development of colleagues moving into leadership roles.   

Actions taken immediately after the inquest:  

Our Director of Midwifery has taken HR advice and concluded that given:   

•  The time elapsed from the event   
•  The disclosures and insights given at the inquest   
•  That the key senior leadership members no longer work for the Trust  

there is nothing further that would be gained from an investigation. The Trust has therefore 
opted to follow a restorative justice pathway that is bespoke to the individuals. Such 
pathways may include:   

•  A skills analysis against the role descriptions    
• 
Individual learning and development plans 
•  Requirement to provide a reflective statement including key learning points from the 
’s and 

’s care following Ida’s death   

matters concerned with 

•  An emotional and psychological support plan    
•  Ongoing support through a professional coach   

What we are going to do next:  

Our Director of Midwifery has developed a skills analysis framework, which will be 
undertaken with all existing midwives who hold senior positions and with all newly-appointed 
senior midwives. This skills analysis will be referred to at the annual performance appraisal 
and will inform the continuous learning and development plan for each individual.   

Westmorland General Hospital 
Burton Road  
Kendal   
LA9 7RG  
Tel: 01539 732288 

INTERIM CHAIR: 
CHIEF EXECUTIVE: 

 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
  
 
 
 The Board has asked the internal auditors to: 

• 

review the embeddedness of the Kirkup recommendations or their successor 
practices. 

•  provide assurance that the governance arrangements in the three divisions are 

operating in line with the Trust’s Quality Governance Accountability and Performance 

Accountability Frameworks. 

•  evaluate the operating effectiveness of controls and level of consistency in place for 
the management, recording, monitoring and reporting of Serious incidents following 
the adoption of PSIRF. 

C: Mandatory Training, expired training and remedial training 

During the course of the inquest, it became clear that the midwife providing primary care to 

 had not completed every element of her mandatory education. Some elements 

of the K2 fetal monitoring package had been completed, but not the full package.  K2 is an 
interactive online, e-learning package which offers modules in fetal monitoring and maternity 
crisis management.  All fetal monitoring modules required completion for the staff member to 
be fully compliant with the K2 training.  K2 is no longer in use by the organisation and has 
been replaced by a fetal monitoring study day, which includes a competency assessment. It 
also emerged that the senior midwife was, at the time of the inquest, not compliant with the 
requirement to undertake annual neonatal resuscitation. On hearing this information, the 
Director of Midwifery immediately issued a direction for this to be rectified within 24 hours. 
The senior midwife successfully completed her mandatory education the next day. 

Each year, the Trust must achieve 10 safety standards in order to be eligible for a 10% 
rebate of contributions to the Clinical Negligence Scheme for Trusts (CNST). Safety action 8 
requires Trusts to have a minimum 90% attendance for three elements of training and 
education: 

•  Fetal monitoring training   
•  Multiprofessional maternity emergencies training (PROMPT)   
•  Neonatal life support training   

The Trust has consistently demonstrated 90% compliance for all three areas.   

Previously mandatory education has been considered a personal professional responsibility. 
However, the fetal monitoring guideline published in 2023 states that any clinician who is not 
compliant with fetal monitoring will have restrictions placed on their practice until relevant 
training is completed.  

Actions taken prior to the inquest:  

The Director of Midwifery commenced a body of work before the inquest concluded which 
has involved:   

•  A weekly compliance report   

Westmorland General Hospital 
Burton Road  
Kendal   
LA9 7RG  
Tel: 01539 732288 

INTERIM CHAIR: 
CHIEF EXECUTIVE: 

 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 •  Personal contact with all clinicians not compliant to remind them of their obligations 

and agree a plan   

•  Provision of a plan and timeframe for all clinicians whose compliance had lapsed   
•  Work with the obstetric education lead to include obstetric medical compliance as 

•  A requirement for mandatory education to be included in individual annual 

well as midwifery compliance    

performance appraisals    

•  An analysis of mandatory education compliance is now reported to the Board for 

oversight at the highest level  

What we are going to do next:  

Map all critical training requirements for clinical areas and ensure compliance across the 
Trust. 

Where there are areas of concern, provide training and development to improve skills, 
knowledge and behaviours. 

D: Grading of harm for incident reporting: Babies who have sustained hypoxic brain 
injury and undergo cooling  

We acknowledge that the grading of harm of the incident should have been reviewed and 
updated to severe once the severity of the hypoxic injury was known.  

As part of our refreshed Governance processes, we introduced a daily triage of incidents 
(see also p3). This is attended by members of the Divisional leadership teams, Corporate 
Clinical Governance team and Chief Nursing Officer team. This daily triage is accountable to 
the Executive Review Group (ERG). The function of the daily triage is to triangulate events 
captured through a variety of routes (i.e. incidents, complaints etc.) and agree the most 
appropriate learning response based on the Trust’s Patient Safety Incident Response Plan 
(PSIRP) which includes the potential for learning, improvement and systemic risk.   

Any incident that is graded as moderate harm or above triggers the Patient Safety Incident 
Response Framework (PSIRF) incident management response - this ensures that a 
comprehensive independent investigation is undertaken. The Trust has also introduced local 
maternity PSIRF priorities, since there is a lack of national guidance about the response 
when an incident falls outside the national reporting structure for MNSI and Perinatal 
Mortality Review Tool (PMRT). We have triangulated data from complaints, moderate and 
serious harm incidents to develop our local priorities. Neonatal seizures not meeting cooling 
criteria is one of those priorities. Any incident that meets the local priorities criteria is 
escalated for executive oversight of the incident management process.  

The ERG is chaired by the Chief Medical Officer or Chief Nursing Officer. The group is 
convened twice weekly to oversee all incidents reviewed by the Divisions that have been 
validated as causing moderate or above harm. In addition to this, the group may review 
other incidents that trigger organisational concern. The group also reviews all complaints 
and claims received in the previous week. This process enables executive oversight of any 
immediate issues which need addressing. The group has the power to investigate any 

Westmorland General Hospital 
Burton Road  
Kendal   
LA9 7RG  
Tel: 01539 732288 

INTERIM CHAIR: 
CHIEF EXECUTIVE: 

 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 clinical or non-clinical activity within its terms of reference. It is authorised to seek any 
information it requires from any employee and all employees are directed to co-operate with 
any request made by the ERG.  

What we are going to do next:  

We are in the process of employing three full-time Learning Response Leads who will 
conduct investigations and provide oversight of the PSIRF process. 

Embed enhanced quality assurance of Patient Safety Incident Investigations through a 
structured process involving members of the Chief Nursing Officer and Corporate Clinical 
Governance teams. 

E: Funding for MSNI  

Concern not addressed to the Trust. 

We hope this information is of reassurance but should you require anything further, please 
do not hesitate to contact us. 

Yours sincerely 

, Interim Director of Governance and Assurance on behalf of 

, Chief Executive 

, Chief Nursing Officer 

, Director of Midwifery 

Westmorland General Hospital 
Burton Road  
Kendal   
LA9 7RG  
Tel: 01539 732288 

INTERIM CHAIR: 
CHIEF EXECUTIVE: