New investigation helps scandal hit trust to learn lessons

The University Hospitals of Morecambe Bay Foundation Trust commissioned the expert review into the death of Joshua Titcombe to tackle unanswered questions and ensure learning.

The trust has also facilitated a reconciliation meeting between Joshua’s father, James Titcombe, and one of the midwives implicated in his son’s death.

Mr Titcombe praised the trust saying: “After eight years I feel I can hand over the responsibility to the trust now. It feels for the first time that the trust owns what happened to Joshua, they understand it, and they accept it. I don’t feel I am at odds with the trust anymore.”

The report has been shared with HSJ ahead of the anniversary of Joshua’s death from unrecognised sepsis on 5 November 2008.

Trust chief executive Jackie Daniel said she believed the process followed by the trust was a model other NHS organisations could follow.

Last year, the Kirkup inquiry identified the Furness General Hospital maternity unit as dysfunctional and responsible for the avoidable deaths of 11 babies and one mother.

Experts from Central Manchester Foundation Trust identified 22 key findings and 18 recommendations for the trust in the latest investigation.

The report says there were basic care failings in the treatment of both Joshua and his mother Hoa, including:

• Joshua “would have almost certainly survived” had thorough observations and escalation to a consultant paediatrician taken place leading to him being given urgent antibiotics.
• The panel said it was “highly improbable that there were normal neonatal observations” on the morning Joshua collapsed. A statement from a midwife that all the observations were normal was described as “not a credible view”. Notes from the time have gone missing.
• The standard of care Hoa Titcombe received was “not safe” and the positive outcome for her was only due to “fortuitous use of a broad spectrum antibiotics” rather than proper careful assessment and monitoring.

In a summary of the report, the trust said: “It is evident that if the case had been investigated in a timely, comprehensive, open and robust way, such fundamental lessons could have been learnt and actioned much sooner. In reality, many of changes needed to meet the recommendations of the review were not meaningfully implemented until 2012-13, some five years after Joshua’s death.

“Had this happened earlier, this would have led to better clinical outcomes for others. The themes addressed by these recommendations were apparent in other serious incidents that continued to occur at the maternity unit for a number of years after Joshua’s death.”

The trust also arranged a reconciliation meeting, facilitated by Androulla Johnstone, chief executive of the Health and Social Care Advisory Service, for an “honest discussion” between one midwife and Mr Titcombe.

Ms Daniel said: “It was an incredibly emotional meeting. The midwife was able to say to James that she failed Joshua and would carry that with her every day. It was a relief for her to be able to say that but what then happened was that James was able to say that he forgave her. What happened in that moment was amazing and very healing.”

She added: “This is the first investigation looking at the whole case and dealing with all the unanswered questions. The one thing I really regret is we should have done this earlier on. What is obvious all these years later is that there are so many things to learn when you do this properly. We had other people’s opinions but it has been really important for the trust to take its own look and it illuminated things that perhaps we would never have known about.”

Mr Titcombe, who campaigned with other families to expose failings at the hospital said: “Many opportunities have been missed to ensure an investigation like this was carried out earlier. In 2010 the ombudsman refused to investigate, telling us that there would be ‘no worthwhile outcome’. The [Nursing and Midwifery Council] also needs to reflect on the finding of this report and it still hasn’t finished its processes after eight years. This report clearly highlights issues that the NMC should have investigated and acted on much sooner and they now need to ensure they learn from their failure to do this so similar mistakes aren’t repeated in the future.”

He said the investigation had revealed new things and answered questions about the care of his wife and son.

On the reconciliation meeting, he said: “What I realised was how absolutely deeply affected by Joshua’s death she was and she took a lot of blame and responsibility for what happened and was actually grieving as well. I have definitely forgiven her and I have told the trust that she should be supported.”

He said other NHS trusts should be encouraged to follow similar processes to investigate errors and poor care. “If you are going to learn, you have to have a proper investigation and it is putting other patients at risk if you don’t do that,” he said.