Between 2004 and 2013, 16 babies and three mothers died in a maternity unit at Furness general hospital. One of those babies was my own son. Joshua died on 5 November 2008 of profuse internal bleeding to his left lung. A series of serious failures before and after his birth resulted in an infection that could have easily been cured with antibiotics going untreated until he collapsed 24 hours after he was born.
After nine days of fighting for his life, Joshua died at the Freeman hospital in Newcastle despite the very best efforts of the dedicated neonatal intensive care staff.
The trauma of Joshua’s death will be forever etched on our minds, but it is no exaggeration to say that the hardest part of coming to terms with his loss was the way Morecambe Bay NHS trust (responsible for the hospital) and the wider healthcare system, responded.
Critical medical records mysteriously went “missing”, and various local investigations were less than honest. In March 2015, Dr Bill Kirkup published his long-awaited report looking at provision of maternity care at Furness general hospital (FGH) between 2004 and 2013. It found “a lethal mix” of failings had contributed to the deaths of babies and mothers. Ultimately, other babies have continued to die in the years since Joshua’s death, and I’ve met dozens of families whose experience has, sadly, been strikingly similar.
While we have now finally seen transformational progress at the hospital that failed Joshua, yet another report was published this week highlighting the urgent need for national change. It looked at the quality of care in the case of stillbirths and neonatal deaths that occurred in 2015, reviewing a sample of 78 of the 225 cases. The report echoes the findings of a number of other recent maternity reports, concluding that eight in 10 of the deaths were potentially avoidable, and that in around a quarter of deaths there was ineffective communication between the health professionals delivering care. The report found a “common issue” of staff failing to recognise an evolving problem, or the transition from normal to abnormal.
Although the report falls short of spelling it out, these findings highlight the importance of the recent move away from the national Royal College of Midwives campaign for “normal” – in other words, non-medical birth – towards a focus on ensuring women and their babies get the best and most appropriate care for them. The report also highlights that in around a quarter of cases, “capacity issues” were identified as a problem. Having the right number of appropriately skilled staff is crucial for the provision of all safe healthcare, but the issues affecting maternity safety are clearly much wider and complex than whether we have enough midwives and obstetricians.
Perhaps of most concern, the report found that most local investigations into the cases reviewed were of poor quality, with 90% failing to fully follow the existing guidelines. This shows the extent to which our health system isn’t learning from serious errors that lead to tragic and unnecessary deaths; rather, these sorts of mistakes continue to repeat themselves.
The Morecambe Bay inquiry recommended that all stillbirths and neonatal deaths should in future be subject to a standardised process of independent investigation, including input from and feedback to families. While it can certainly be argued that progress could have been quicker, this week the health secretary, Jeremy Hunt, has announced some monumental changes that I’ve long campaigned for. From April 2018 all cases of term stillbirths, neonatal deaths, brain-damaged babies and mothers who die giving birth will be independently investigated under the leadership of the new Healthcare Safety Investigation Branch (HSIB).
This is the ultimate response to Morecambe Bay and many other tragic cases that we know could be avoided with safer maternity care. These expert investigations will be a major step towards ensuring that no bereaved family is left having to fight for answers about what happened and why, and will hopefully provide a framework that can be expanded to other areas of healthcare in the future. Such expertise should provide great reassurance to healthcare staff by ensuring the focus is on system learning and not unwarranted blame.
As Bill Kirkup wrote in his report, “all healthcare – everywhere – includes the possibility of error. The great majority of NHS staff know this and work hard to avoid it. They should not be blamed or criticised when errors occur despite their best efforts. But in return, those who work for the NHS owe the public a duty to be open and honest when things go wrong … to learn from what has happened. This is the contract that was broken in Morecambe Bay.”
Providing safe healthcare is a hugely complex task; overnight transformation is unlikely. But I believe that the reforms announced by Jeremy Hunt this week offer by far the best hope yet of ensuring that in future the unwritten contract Kirkup describes in his report is never broken again. While we may never be able to eradicate NHS tragedies like Joshua’s death, we can and must ensure we do everything possible to learn from them.
• James Titcombe OBE is a patient safety campaigner and father of Joshua Titcombe, who died nine days after being born in 2008 at Furness general hospital
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