3 hours agoShareSaveMichael BuchananSocial Affairs CorrespondentShareSaveBBCBy the entrance to Furness General Hospital in Barrow-in-Furness sits a sculpture of a moon with 11 stars. It is a memorial to the mother and babies who died unnecessarily due to poor care at the hospital between 2004 and 2013.Inscribed underneath is a short verse: "Forever in our hearts; Forever held in the love that brought you here; Our star in the night sky, spring blossom, summer rose, falling leaf, winter frost; Forever in our hearts."When the memorial was unveiled in 2019, Aaron Cummins who is chief executive at University Hospitals of Morecambe Bay NHS Trust, which runs the hospital, said: "We will never forget what happened. We owe it to those who died to continually improve in everything that we do."Barely a month later, Sarah Robinson stepped into a birthing pool at the Royal Lancaster Infirmary, a hospital run by the same NHS trust. She was about to give birth to her second child.Within an hour, Ida Lock was born; within a week, she was dead.PA MediaWhat her parents were put through on that day - and in the years since - goes a long way to explaining why maternity services in England have failed so many families.The inquest into Ida Lock's death, which concluded last week, exposed over five weeks why maternity services across England have long struggled to improve - and this one case holds a mirror to issues that appear to be prevalent across a number of trusts.'I thought I'd done something wrong'The memorial the trust erected at Furness General Hospital followed a damning inquiry into the trust's maternity services. That investigation, carried out by Dr Bill Kirkup and published in March 2015, found there had been a dysfunctional culture at Furness General, substandard clinical skills, poor risk assessments and a grossly deficient response to adverse incidents with a repeated failure to properly investigate cases and learn lessons.Morecambe Bay became a byword for poor maternity care and the trust promised to enact all 18 recommendations from the Kirkup review. And yet that never happened. "We wouldn't be in this situation now if they'd followed those recommendations," says Ms Robinson.Ida Lock's inquest began last month, more than five years after she died - the delay was down to several reasons, including its particular complexity.What emerged was just how profoundly many of those lessons had not been learned. Particularly egregious, says Ms Robinson, was a suggestion from a midwife - shortly after the birth - that Ida's poor condition was linked to her smoking, something Sarah had never done in her life."The amount of days I cried because I thought I'd done something wrong... every Christmas, every holiday, you always have this heavy weight that you shouldn't be having fun. And all along, some people knew."Meanwhile, the staff who had delivered Ida were told in an email that "they had demonstrated excellent teamwork, and had all worked in the best interests of mum and baby".As the coroner found on Friday, Ida's death was wholly avoidable, caused by a failure to recognise that she was in distress prior to her birth, and then a botched resuscitation attempt after she was born. By the time she was transferred to a higher dependency unit, at the Royal Preston hospital, she had suffered a brain injury from which she could not recover.Having failed to deliver their daughter safely, Ida's parents would have expected that the trust would properly and openly investigate her death. Instead, they pursued an investigation that Carey Galbraith, the midwife who completed it, would later describe as "not worth the paper it was written on".They didn't take responsibility for their failings despite having an independent report from the Healthcare Safety Investigation Branch (HSIB) - a body that examined questionable maternity care - clearly stating their shortcomings."Our efforts to get any answers have been met with a complete block," said Ida's father, Ryan Lock. "Particular people have told us to our face something that wasn't the case, that Ida was poorly before she was born, and that's the reason why that this happened."PA MediaClearly, the Morecambe Bay report was not, as was hoped, a line in the sand for maternity services across England, or a rallying cry for widespread improvements. As the inquest has shown, it did not even lead to sustained improvement at Morecambe Bay. Tabetha Darmon, chief nursing officer at the trust, said in a statement last week that it has made improvements since."We take the conclusions from the coroner very seriously and have made a number of the improvements identified during the inquest. We are carefully reviewing the learning identified to ensure that we do everything we can to prevent this from happening to another family."'A woeful picture' nationwideElsewhere around the country, other trusts have also been forced to face their failures, often by grieving families.In March 2022, an investigation into services at the Shrewsbury and Telford NHS trust found that more than 200 mothers and babies could have survived with better care. Then, in October that year, a review into maternity services at East Kent Hospitals University NHS trust found that at least 45 babies might have survived if they had been given proper treatment. And an ongoing review into the maternity care provided by Nottingham University Hospitals NHS trust, due to be completed next year, is set to be the biggest yet, with around 2,500 cases being examined.Even that does not tell the full story. Families in several areas, including Sussex, Leeds and Oxford, want local investigations into their maternity services. And an annual review of units by inspectors the Care Quality Commission (CQC) paints a woeful picture.In the commission's latest report, published in September, not a single one of the 131 units inspected received the top rating, Outstanding, for providing safe care.About a third (35%) were rated as Good for safety, around half (47%) were rated as Requires Improvement while almost a fifth (18%) were deemed Inadequate, the lowest grading."While we identified pockets of excellent practice," wrote the CQC, "we are concerned that too many women and babies are not receiving the high-quality maternity care they deserve."Professor James Walker, who used to be the clinical director for HSIB, said that from his visits around England, the problem was that maternity units "didn't have the skills, the finances, or the drive to actually make the changes that are required."Ida Lock's inquest was a case in point. What emerged over the inquiry was that the midwife delivering Ida was not compliant with crucial training in heart-rate monitoring, that staff did not know how to investigate incidents or realise they should inform external regulators of an unexpected death."It's deeply distressing," says Dr Kirkup. "It's bad enough that other trusts didn't listen, but for it to happen again in this same trust is unforgivable."From poor culture to lack of teamwork Listening to his exasperation brought me back to the autumn of 2022. On that bright morning, Dr Kirkup was speaking at the publication of his inqu ...