The Morecambe Bay Investigation, chaired by Bill Kirkup, published its report on 3 March. ‘The name of Morecambe Bay,’ it says, ‘has been added to a roll of dishonoured NHS names that stretch from Ely Hospital to Mid-Staffordshire.’ The report isn’t about the town of Morecambe, but deals with the dreadful things that happened for nearly a decade across the bay at Furness General Hospital (FGH) in Barrow, part of the University Hospitals of Morecambe Bay Trust.

The Furness maternity unit was dysfunctional and dangerous. Eleven babies and one mother died from preventable causes. Others were harmed. The midwives’ policy was normal childbirth ‘whatever the cost’. They were a close-knit group who called themselves ‘the musketeers’. They distorted the truth. One senior midwife was not only the maternity risk manager, and so carried out investigations of bad outcomes, but also the union staff representative – an unacceptable conflict of interest.

The coroner at the inquest on Joshua Titcombe could only speculate why a crucially important document recording events during the first day of his life was lost, and thought that the midwives giving evidence had been helped by the circulation of ‘model answers’. He died in 2008 from an infection. It was a hard death; he was transferred from Barrow to Manchester and then helicoptered to Newcastle to receive ECMO by heart lung machine, but after nine days had a fatal bleed into a lung lobe destroyed by the infection. If he’d been treated early, his chance of survival would have been at least 80 per cent.

The maternity unit was dysfunctional for years. The midwives sought to avoid the involvement of the obstetricians, who in turn had poor working relationships with the paediatricians, who had bad relations with each other. No connection was made between repeated adverse events: ‘Sometimes bad things happen in maternity – people just have to accept it,’ one of Kirkup’s witness said. The external regulators failed too. So did the Trust. Its biggest hospital is the Royal Lancaster Infirmary.

The RLI had an enormous influence on my career. I attended many post-mortems there as a medical student. Visitors to Morecambe were often on the slab. ‘Dad’ in Alan Bennett’s TV play Sunset across the Bay dies from a stroke in a Morecambe seafront lavatory. Some of those I saw at the RLI had been found at the foot of the stairs in a Morecambe boarding house and had bled into their brains. Had they fallen because of a stroke, or had they tripped and hit their head on the way down?

There have been management changes at the Morecambe Bay Trust. I wish it well. James Titcombe, Joshua’s father, has moved from process management at Sellafield to the Care Quality Commission as the national adviser on Patient Safety, Culture and Quality. The nuclear industry has a safety culture that is far better than that in the NHS. I wish him well too.