The Report of the Morecambe Bay Investigation.
Sharing information about large-scale investigations into failures can provide insights on factors that contribute to adverse clinical incidents. This report discusses an analysis of care delivered in the maternity unit of a National Health Service Trust between 2004 and 2013 which uncovered problems that were perpetuated due to failure to look into the initial event.
Kirkup B. London, UK: The Stationery Office; 2015. ISBN: 9780108561306.