Birth Choice and Information

For some time now I’ve notice a promoted tweet from Which appearing on my timeline linking to a ‘Birth-choice Tool’. The tool is supported by the Royal College of Midwives (RCM), with the Chief Executive of the RCM Cathy Warwick saying that it will “…go a long way towards helping them [pregnant women] make an informed choice and to decide what is the best place for them to give birth.”

The tool has also been endorsed by Julie Cumberlege, the Chair of the National Maternity Review who (see tweet below) also makes a link with Personal Maternity Care  Budgets. (This was a pre decided recommendation of the National Maternity Review).

jc

Providing unbiased information to women and their families so that they can make informed choices about birth-place is clearly important and positive. This is something I can’t see anyone objecting to. But the emphasis here must be on accurate and unbiased information. To this end, I got a bit of a shock when I used the tool and entered various scenarios.

I’ll go through a worked example here.

The first question the tool asks is under the heading ‘Your birth experience’ and asks the question ‘Do you think you will want to use a birthing pool during labour?’.

q1

Of note, the tool cites the benefits of a birthing pool as being coping with pain and being less likely to need an epidural. There is no discussion around published studies around potential risk and benefit.

The next question is ‘Do you think you will want an epidural?’.

My only comment here is that I can imagine for some first time mums they won’t know what to expect or how they will experience pain. Would a better question be ‘do you want to keep the option of having an epidural open’?

On to the next question… ‘How do you see birth’?

q3

I have to say this is the point at which I began to feel really concerned. The tool gives two options.

  1. As a natural event that should take place in a relaxed and private setting.
  2. As a clinical event that needs medical equipment and staff on hand.

It seems to me that the language here is very loaded; ‘natural, relaxed and private’ vs ‘clinical, medical and equipment.’

Is it the case for example that birth in an obstetric led unit can not be ‘relaxed, natural and private’?

The tool then asks the question ‘Are you willing to plan for the possibility of transfer during labour’?

q4

The explanation note does point out that if you plan to give birth at home or in a birth centre you may have to be transferred. It highlights that that such a choice  ‘can reduce your chance of needing medical interventions.’ There is however no mention that for first time mums the transfer rate nationally is 36-40% and there is no discussion about the implications for the safety of mother or baby in the case of a complication arising that necessitates obstetric intervention.

The tool then asks for your age, if it’s your first birth and what your post code is.

In some scenarios, before coming up with the recommended options, the tool will ask an additional question:

q5

‘Do you actively want to avoid the need for medical intervention’?

I have to admit to surprise  when I read this. No matter what choice a woman and her family make about place of birth it surely isn’t possible to ‘avoid the need for medical intervention’. It might be possible to make choices that reduce the chance of experiencing an intervention that may not have been necessary. However, this is complex and in reality, many lives are saved by virtue of mothers giving birth in a setting where risks are carefully monitored and midwives and doctors train and work together to respond to obstetric emergencies promptly. For example, the obstetric unit at Southmead is regarded as one of the safest places anywhere in the world to have a baby.

Nowhere in the tool are the risks associated with childbirth quantified. For example, in 1999 the World Health Organisation (WHO) published research that showed that globally around 15% of all births are complicated by a potentially fatal condition that requires emergency care.

Academic research also that shows that your risk of death is greater on the day you are born, than any other day of your life until you reach the age of 92.

The things that can go wrong in childbirth (for example sepsis, amniotic fluid embolism, haemorrhage, placental abruption, pre-eclampsia) are not things that can be controlled by making a choice about birthplace. They are complications that on rare occasions,  women and babies sadly continue to die from unnecessarily because interventions (sometimes as simple as a single of dose of antibiotics) were denied.

What did the Birthchoice tool recommended in my imagined scenario?

I live approximately 2 miles from Furness General Hospital (FGH). This is a unit that has recently been through a period of significant change and improvement. In many ways, the unit at FGH is now a leading one in terms of safety, quality and experience.

I completed the Birthchoice tool as a young first time mum, 19 years of age with my postcode. I answered all the questions  leaving the slider in the middle (in reality I think the language in the questions is so loaded that I can’t see how it wouldn’t influence the responses). These are the recommendations the Birthchoice tool made:

results

In my scenario, the tool recommended a freestanding midwifery unit in Penrith, 62.8 miles from my home as a better choice than the unit at Furness General Hospital (FGH) which is just 2 miles away. This recommendation is made for a 19-year-old first time mother.

I always find it interesting to observe the wider context when I come across things like this.

Last week HSJ covered this story stating that there will be a doubling of ‘midwife-led births share by 2020’.

A week earlier, I noticed the following tweets from a midwifery conference attended by senior NHS and RCM midwifery leaders.

o-v

v-worrying

The tweet says “Obstetric violence, we have all seen it…” and shows what seems to be a video with a male doctor (presumably an obstetrician) and the words ‘No, no, no. Stay there quietly’. Someone comments that the phrase is worrying and the response is,  ‘it’s very worrying… & exists’.

Last week I also took the time to watch a presentation from Bill Kirkup about events at Morecambe Bay where 16 babies and 3 mothers lost their lives. If you have the time, please watch it also. It is hard for me to reconcile the messages in Dr Kirkup’s report with some of the observations I’ve highlighted in this blog.

I know that there are many fantastic people working hard to ensure safer maternity care is a priority, but is it now time that we saw some national leadership in challenging these issues? If so, would a good place to start be by providing a resource for women and families that really did provide unbiased and accurate information to enable informed choice? Instead of conferences that promote ‘normality’ in childbirth and appear to promote negative messages relating to obstetricians that must be very frightening for women to see, shouldn’t we be holding conferences attended by all professionals involved in delivering maternity care, where we celebrate teamwork, discuss and learn from poor outcomes, listen to all voices and agree actions we can take together to make maternity care safer and better for everyone.

James Titcombe – 8th Jan 2017

A few thanks…..

2016 has been a very busy year personally and for patient safety in England. I wanted to write a quick blog to thank a few people who have made a difference.

In February, a report commissioned by NHS England relating to the tragic loss of baby Kate Stanton-Davies in 2009 was published. The report only came about because of the hard work and determination of Kate’s parents Richard and Rhiannon. The report was shocking for many reasons, including the fact findings  were very different to the initial supervisory investigation carried out following baby Kate’s death and identified failures that had previously not been acknowledged.The report also made the recommendation for there to be a national audit of the quality of similar supervisory investigations following serious incidents/avoidable deaths in maternity services. A big thank you to Richard and Rhiannon for all they have done to push for the truth about Kate’s loss and for there to be national learning. 2017 will be an important year for midwifery and a new model of supervision is being developed, it’s vital that Kate’s story and the results of the national audit feed into the new model.

It’s been approaching 2 years since the Morecambe Bay Investigation report was published. If I’m being frank, I have a growing concern that some of the key messages of the Morecambe Bay report, especially amongst some elements within Midwifery, risk being lost and overlooked. However, since publication, the Chair of the Morecambe Bay Investigation Dr Bill Kirkup has consistently and superbly kept a focus on the issues. This has included articles and talks at high profile events about what happened at Morecambe Bay and what the keys message are.

If you only have 30 mins to spare to learn about Morecambe Bay, please watch this talk from Bill, it’s so important that these messages aren’t lost or forgotten.

I’d like to repeat my thanks to the whole Morecambe Bay Investigation panel, but especially to Bill Kirkup for working so hard to spread the learning from his report.

Another area of significant progress in 2016 has been the establishment of a new Healthcare Safety Investigations Branch (HSIB), which is set to go operational in April next year.  This new body has come about as a consequence of sustained effort from people like Martin Bromiley and the Clinical Human Factors Group (CHFG) and others. A breakthrough moment was when Carl Macrea and Charles Vincent published their paper ‘Learning from failure: the need for independent safety investigation in healthcare’ towards the end of 2014. The paper was read by Bernard Jenkin MP, the Chair of Public Administration Select Committee (PASC) who also became a passionate champion for the creation of the new body and set up a PASC inquiry which made recommendations that the government supported.

Another person who in my mind has made a huge difference in 2016, is the Patient Safety Correspondent at the HSJ, Shaun Lintern. I highly recommend watching this recent talk by Shaun which highlights the mountain that we still have to climb in improving safety and culture in the NHS. I also recommended this piece and hope 2017 will be a year we make real progress in changing this.

Earlier this month, the Care Quality Commission (CQC) published a comprehensive report into the quality of investigations and learning following the deaths of patients in the NHS. This is a report that everyone working in healthcare should read. It wouldn’t have come about without the considerable efforts of the family of Conner Sparrowhawk, whose preventable death whilst in the care of Southern Health (and the appalling way the trust responded), triggered the Mazars report and subsequently the CQC review.

Before 2017 arrives, I’d like to say a big thank you to the Chief Executive of Morecambe Bay, Jackie Daniel and all the staff at the Trust. My relationship with Morecambe Bay has been a turbulent one since Joshua’s death as until recently, I have felt that there has been a lack of ownership for what happen and that questions about what happened to Joshua and why remained unanswered.

I must say that during the past year, Jackie and the team at Morecambe Bay could not have worked any closer with me to resolve this. Jackie has shown huge understanding, thoughtfulness and compassion.

As part of the work the Trust did with me, it was discovered that a senior midwife central to events at the trust and involved in a flawed investigation into Joshua’s death, had received an ‘irregular payoff’ in a deal that avoided an internal trust investigation. Before these facts were made public, Jackie was issued with a legal injunction by the Royal College of Midwives (RCM) to try and ensure the circumstances of what happened were kept secret. I think it shows huge moral courage that Jackie ignored the legal threat and did the morally right thing by releasing the report regardless.

On 4th November 2016, a day before the 8th anniversary of Joshua’s death, the Trust published a summary report of their recent investigation on their website.

The report is honest, thorough and accurate. I now feel that the Morecambe Bay trust genuinely does ‘own’ what happened to Joshua and I  believe that they will ensure the lessons from his death and other tragic events, are never forgotten.

In 2008, it is now abundantly clear that Morecambe Bay was a trust that had much to learn from the wider NHS. As we approach 2017, I honestly believe that it is the wider NHS that has much to learn from Morecambe Bay. Once again, huge thanks to Jackie and the team at Morecambe Bay for all your hard work.

It’s not possible to mention all the other people who continue to make a difference, but thanks to everyone who works to make healthcare safer and wishing you all a very Happy New Year and all the best for 2017.

James Titcombe – 31.12.16

Holding up the mirror

I was disappointed to see some of the news reports following the publication of the CQC inspection report of Bellevue GP practice, where CQC Chief Inspector of Primary Care Steve Field is a partner. 

What was even more disappointing was to see the reaction from some primary care professional (see comments here) which included calls for Field to resign. The full inspection report for the practice is well worth a read

Overall it’s a very good report and describes a service that is well led and indeed delivers outstanding care in some areas. The furore has been caused because the inspection highlighted a few specific areas where CQC felt improvements were needed, particularly around reviewing patients with prescriptions for high risk medication.

For me, far from being a resigning matter, the Bellevue inspection report is something that Field should be in no way embarrassed of. It demonstrates that even well led, caring, effective and responsive organisations need to continuously look for opportunities to improve. The NHS in general would benefit from embracing a culture more accepting of this. Highlighting problems and areas for improvement only becomes a real problem when the response is defensive and changes aren’t made.

The report clearly demonstrates that the inspection process which Field oversees is comprehensive, puts patients first, is independent and most importantly, has the integrity to hold a mirror up to the quality of care being delivered without fear or favour.

Some of us have memories of a very different looking CQC that appeared more interested in it’s own reputation than the safety and experience of the people using the services it is was there to oversee. 

The Bellevue inspection is a sign of how far things have come and something Field and CQC as a whole ought to be proud of.

An open letter to Cathy Warwick – 16/10/16

Dear Ms Warwick,

I am writing this open letter to you following the revelations widely reported in the HSJ and other national media last week. 

As you will be aware, in March 2015 the Kirkup report concluded that 11 babies and 1 mother died as a consequence of ‘a lethal mix’ of failures at Furness General Hospital (FGH) from 2004 to 2012. The report states:

“Many of the reactions of maternity unit staff were shaped by denial that there was a problem, their rejection of criticism of them that they felt was unjustified (and which, on occasion, turned to hostility) and a strong group mentality amongst midwives characterised as ‘the musketeers’. We found clear evidence of distortion of the truth in responses to investigation, including particularly the supposed universal lack of knowledge of the significance of hypothermia in a newborn baby, and in this context events such as the disappearance of records, although capable of innocent explanation, concerned us. We also found evidence of inappropriate distortion of the process of preparation for an inquest, with circulation of what we could only describe as ‘model answers’. Central to this was the conflict of roles of one individual who inappropriately combined the functions of senior midwife, maternity risk manager, supervisor of midwives and staff representative.”

You will be aware that the case being discussed here (as detailed later in the Kirkup report) is that of my son Joshua and that the ‘individual’ in question is the person identified in last weeks report as having received an ‘irregular’ payoff in 2012. The report found that the individual ‘appears to have been significantly overpaid’ in a deal described as ‘very irregular in terms of no governance process being followed’. The deal also included an agreement that the trust would not ‘commence an internal investigation into the employee’s performance as maternity risk manager.’

After my son died, the individual in question wrote a supervisory report about his death which was described by the Kirkup report as ‘fundamentally flawed’. 10 babies died following serious failures in care at FGH after my son died. I know that no one goes to work in the NHS to cause harm but to quote from the Kirkup report ‘…where individuals collude in concealing the truth of what has happened…their behaviour is inexcusable.’

You will be aware that following the publication of the Kirkup report, the trust themselves have been working incredibly hard to make improvements; not just to put right the serious deficiencies that led to harm in the past, but to go further with an ambition to be one of the safety maternity units in the country. To the credit of the Chief Executive Jackie Daniel, this commitment to truly learn and be open and transparent about past wrongdoing is being demonstrated by actions as well as words.

The circumstances revealed by the report last week are deeply concerning. An individual with serous questions to answer relating to the tragic events at Morecambe Bay, rather than being subject to a process of investigation to facilitate learning and change, instead was ‘significantly overpaid’ with tax payers money in an exit deal outside any proper governance process.

Despite the shocking legal threat from the Royal College of Midwives attempting to block the release of this report, Jackie Daniel demonstrated last week the trust were no longer willing to bury information and instead chose to be open, honest and transparent.

Rob Webster, former Chief Executive of the NHS Confederation and current Chief Executive of South West Yorkshire NHS FT described Jackie’s actions on twitter as a ‘great example of values based leadership from one of the best CEOs I know.’ Many others have spoken out to say the same.

In this light I was deeply shocked to see the threatening RCM statement which you forwarded to me by email on Friday 14th October which states “The RCM is carefully considering its options to pursue the trust and those involved in the decision to disclose this confidential information’.

John Chrisholm, the Chair of the BMA Medical Ethics Committee said on twitter that these actions are a ‘serious and shameful misjudgement by the RCM’. I would go a step further; the RCM state proudly that they are ‘the UK’s only trade union and professional organisation led by midwives for midwives’ but these actions not only let down a hardworking trust as they seek to make positive changes and demonstrate candour, they let down all of your members who deserve their trade union and professional body to act ethically and with integrity.

I urge you cease these threats and instead use your resources to investigate the role of RCM in helping to negotiate this deal, its implications for patient safety, the hurt and distress caused to families whose loved one’s died as a consequence of the wrongdoing involved, the careless use of tax payers money and the damage such deals cause to the confidence and trust of patients and staff who righty expect the NHS and organisations like the RCM to behave in an ethical way.

If you unable to do this, perhaps it is time that the RCM was led by someone willing to take the organisation in a different direction.

Yours Sincerely,

James Titcombe

16.10.16

Thoughts about the NMC

  
My son Joshua died a truly horrible and completely preventable death in November 2008 following significant failures in his care at Furness General Hospital (FGH), part of the Morecambe Bay NHS Trust. My life has never been the same since. Despite the 7 years + that have now passed since Joshua’s death not a day goes by when we don’t think about him. Even in the happiest of moments Joshua is in our thoughts. We wonder what he would be like now if he was with us and often wish that he was sharing those happy moments with us.

 The past 7 years haven’t been easy but, along with other families affected by what turned out to be one of the worst patient safety scandals in the history of the NHS, we did eventually manage to uncover much of the truth about what went wrong and why. In March 2015, the Morecambe Bay Investigation report Chaired by Dr Bill Kirkup was published. This was a turning point in our journey. Joshua’s death was preventable and contributed to by a ‘lethal mix’ of failures that went on unaddressed for almost a decade. Worse still, Dr Kirkup’s report confirmed that all previous investigations into Joshua’s death (and the majority of the other 20 ‘significant failures’ in care identified by the report) had been woefully inadequate. Critical records had gone missing and there had been deliberate attempts to distort the truth.

 The report was clear that what occurred at FGH was not just a matter of system and process issues (although these were plentiful) but that the behaviour and actions of some individuals as viewed by the investigation panel, represented significant lapses from the professional standards expected of them.

 Recommendation 19 of Dr Kirkup’s report was for the professional regulators (including the NMC) to carry out their own investigations into the actions of individuals.

 Given that 11 babies and a mother died entirely avoidable deaths at FGH (the total extent of harm was much higher) and given that Dr Kirkup’s report confirmed that local investigations into these events were woefully inadequate (or at worse deliberate coverups), it might have reasonably been expected that the NMC might go about this task with some urgency and rigour. What has transpired however, could not be further from such expectations.

 Dr Kirkup has described the NMC’s progress as ‘glacially slow’. 

 In relation to Joshua’s death, the NMC told our family in 2015 that 5 midwives were under investigation and that hearings would be taking place before the end of the year. In September 2015 however, we were told to expect significant delays as the midwives  legal representation (provided in many cases by the RCM) had made submissions to try and prevent the hearings going ahead. I argued at the time that given the seriousness of the allegations (how can it get more serious than the preventable death of a child and subsequent covering up) that the NMC ought to at least issue temporary suspension orders until the hearings took place. This didn’t happen.

 In March this year, 2 hearings did finally take place. My wife and I attended as witnesses and the experience was truly awful. It felt like we were the ones on trial. The midwives barristers tactics were to try and discredit our evidence and cast my wife and I as ‘unreliable’ witnesses. Since then, Dr Kirkup and the Professional Standards Agency (PSA), the organisation that regulates the NMC, have written to express significant concerns about the NMC’s handling of the cases. The PSA described the process and decision of the NMC (to clear both midwives) as ‘deficient’. (The NMC have not provided me with any information relating to how they are responding to the PSA’s serious criticisms and initially refused  to share their correspondence with the PSA with me – an issue we are currently challenging them over.)

 In March 2016, I had a meeting with Jackie Daniel, the current Chief Exec at Morecambe Bay. I think that the trust have made some big mistakes since the Kirkup report was published, not least failing to be more proactive in reexamining events that previously hadn’t been investigated adequately to make sure all appropriate action had been taken. However, I do like Jackie and believe that she is doing her best to move the trust in the right direction. During this meeting, Jackie informed me that a midwife currently awaiting an NMC hearing relating to Joshua had been suspended following a recent baby death. No more details were provided. Jackie wanted to tell me in person as she was aware that the case was likely to be reported in the media.

 Several thoughts occurred to me. Firstly a deep sense of sorrow for the family involved and the life changing consequences for them. Then I reflected on the upcoming cases and Joshua’s care. The upcoming NMC hearings relate to the time when Joshua was still alive and his care the night before he collapsed. After Joshua’s birth, my wife collapsed with an infection. My wife was treated with antibiotics but we were told Joshua was fine. After an alleged call to a paediatrician (all the paediatricians on duty vigorously deny such a call took place), Joshua was placed on enhanced monitoring. All records of this monitoring (including a bright yellow observation chart) went ‘missing’ after Joshua’s death. My wife was concerned for Joshua throughout the night; in the early hours of the morning calling the bell by her bed because Joshua was ‘grunting’ and breathing quickly. He was just hours away from complete collapse but the midwife who examined him didn’t refer him to a paediatric and instead placed him in a heated cot. A low temperature in a baby is a common indication of infection but the midwife claims the reason Joshua was placed in a heated cot was because the room – which my wife remembers being warm – was ‘cold’ – Joshua’s temperature (of which no documented records exist) – was reported as being ‘normal’.

 Joshua’s collapsed from overwhelming sepsis just a few hours later. 

 Joshua did not die straight away. He spent a further 8 days fighting for his life. Firstly in Manchester and then in Newcastle, strapped to a heart and lung machine for babies. He died at 9 days old when his left lung began to bleed. The bleeding became more and more profuse until there was nothing the staff could do. They turned off the heart and lung machine and Joshua died in diabolical circumstances from internal bleeding.

 The midwife involved in Joshua’s care following the call for help was asked to respond to some questions from the NMC in 2009 about her care of Joshua. We later discovered that she emailed her report to a colleague in an email she titled ‘NMC Shit‘ – apparently the title of the email was meant ‘as a joke’.

 My family and I can’t understand why it has taken the NMC nearly 8 years to investigate the actions of midwives involved in Joshua’s care. We have repeatedly raised concerns about the lack of progress and why no action has been taken.

Today, the local paper published an article stating that the midwife suspended following the tragic death in March 2016 had now been sacked by the trust:

 “Following a disciplinary hearing, the member of staff has been dismissed as the panel felt her conduct fell fundamentally below our acceptable standards.”

 I do not know the clinical circumstances involved or whether the midwife’s conduct which the trust say ‘fell fundamentally below… acceptable standards’ was a factor in the tragic outcome (the trusts statement doesn’t make this clear). I do know that Joshua died a terrible and truly preventable death, that my family and I were not told the truth about what happened and that the NMC have failed to take any action despite these circumstances for almost 8 years. I also know that had the NMC implemented the recommendations of the Kirkup review with anything like the expediency that was clearly needed, these hearings would have been completed long before March 2016.

 I can not help but feel deeply sad about these circumstances. I am worried that the NMC are continuing to fail to protect mothers and babies and I believe that urgent changes are needed to ensure that professional regulation of midwives and nurses is fit for purpose.

Safety or Fear?

It’s fair to say that last week ranked as one of the most difficult I’ve had in long time. It was a week of personal sadness and distress, yet also a week where kindness, compassion and hope shone brightly.

To explain, I need to cover some background that I know many people reading this will already be aware of.

In November 2008, my wife and I lost our baby son Joshua as a consequence of failures at Furness General Hospital (FGH) where he was born.

Joshua was born a perfect baby boy, but shortly after his birth, my wife collapsed from an infection and was treated with antibiotics and fluids. She soon made a full recovery. Joshua however, wasn’t so lucky. He wasn’t referred to a doctor (despite many signs of being unwell) until he collapsed at 24 hours of age. He died in horrific circumstances 8 days later as a consequence of the same infection his mother had. He put up a brave fight, but despite the best intensive care the NHS could offer, he didn’t quite manage to pull through.

JOSHUA-TITCOMBE-SO_3446288b

Joshua – 27th October 2008

I’ve written at length about how hard losing Joshua was. It’s no exaggeration to say that our lives have been torn apart. It’s no exaggeration either, to say that the multitude of different organisations we have had to deal with since, have hindered, rather than helped our efforts to establish the truth about how and why our son died.

Fast forward 7 ½ years, through a flawed local investigation, the refusal of the Health Service Ombudsman to investigate, an inquest in 2011, a 3 year Police investigation and a national inquiry that found ‘a lethal mix of failures’ at every level of the system and on Tuesday last week, I find myself arriving at the Nursing and Midwifery Council (NMC) offices in Stratford London.

I’m here for a simple reason. Back in 2008, a few days before Joshua was born, my wife and I attended FGH because my wife’s waters had ruptured. It was exactly 3 weeks before Joshua was due and we’d both been feeling poorly with sore throats and headaches for a few days. We were seemingly well looked after. My wife was monitored carefully and reassured that the illness we described was probably a ‘virus’. We were sent home with advice about what to look out for and to come back if there were any problems. We came back the next day and the same thing happened. Joshua was born early in the morning the day after, at 07.38am on Monday 27th October 2008.

These events, which happened more than 7 years ago, are the reason why I’m here. The NMC allege that the midwives who my wife and I saw over those two days, should have referred my wife to an Obstetrician if they were aware that she was feeling unwell. The issue however, is that the midwives who saw us over that weekend deny that my wife and I had the conversations about feeling unwell that we clearly remember having.

I arrive at the NMC office just before 11am, but I’m kept waiting until gone 1pm before I’m called to give my evidence.

When I enter the room, the atmosphere is cold and hostile.  Before reading my statement, I’m asked not to read my son’s name, but instead to refer to him as ‘Patient A’. I refuse, and after a short exchange, the panel Chair rather crossly agrees that I can read my statement and refer to Joshua by his name, not a letter of the alphabet.

After reading out my statement, I answer some questions from the NMC case presenter. Then, the barristers representing the midwives question me. Their questioning is unpleasant and aggressive.  Clearly their strategy is to do their utmost to discredit my statement and imply that I am an unreliable witness. I answer their questions to the best of my ability, but leave the hearing feeling hurt and upset.

I am then told that the statement my wife prepared and submitted as evidence would not be accepted by the panel unless she attended in person herself. My wife found the prospect of attending the hearing distressing, but when the NMC phoned her to explain that her evidence wouldn’t be considered unless she did attend, she agreed to do so. The NMC asked for the hearing to be adjourned until my wife was able to attend on the morning of Thursday 10th March.

I’m now aware that the barristers representing the midwives submitted an objection to this request, stating “…it was fair to infer that Father A was behind Patient C’s change of heart”.

My wife travelled to London on her own and gave her evidence on 10th March. No-one offered her a word of condolence for her loss and the barristers representing the midwives were aggressive in their questioning. She says that the experience made her feel ‘like a criminal’.  

I couldn’t be with my wife that day because at the very same time she was giving her evidence, I was scheduled to give a talk about my experience losing Joshua at the Global Patient Safety Summit in another part of London.

Before I stood up to talk, Jeremy Hunt gave a powerful speech and announced a range of new measures aimed at developing a stronger learning culture in the NHS.

Hunt quoted Dr.Lucian Leape

The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes

The measures announced include a new Healthcare Safety Investigations Branch (HSIB), operational from April 2016, which will include legal protection for staff to enable ‘a safe space’ for those involved in incidents to be able to speak up.

“This legal change will help start a new era of openness in our response to tragic mistakes: families will get the truth faster; doctors will get support and protection to speak out; and the NHS as a whole will become much better at learning when things go wrong. What patients and families who suffer, what they want more than anything, is a guarantee that no-one else will have to re-live their agony. This new legal protection will help us promise them ‘never again’.”

That evening, the regional ITV news ran a story about the NMC hearings my wife and I had attended that week. An online article was published entitled “Parent’s recollections branded unreliable at midwives hearing.” 

The article read

 Thomas Buxton, representing [Midwife A] said the case against his client should be withdrawn and called the evidence given by Mr and Mrs Titcombe “unreliable”. He told the panel that the mention of being unwell or poorly arose “for the first time at the inquest hearing in June (2011)

The same story was repeated the next day in our local paper, seen by our friends and family.

I read the article with shock, frustration and hurt. What Mr Buxton had said simply was not true. My wife and I made notes about what happened at FGH, including our conversations about feeling unwell, whilst Joshua was still alive. We wrote up these notes and submitted them to the trust just days after Joshua died.

Of course, none of this mattered to Mr Buxton, whose only interest was in putting forward arguments in the best interests of his client. In this case, the best line of defence was to attack the credibility of the evidence which my wife and I had given. He did so in a public legal hearing, without my wife and I present and the person putting forward the case on behalf of the NMC wasn’t even aware that our chronology document existed.

The experience was cold, incompetent and inhumane. I cannot imagine that anything good could ever come from such processes, so long after Joshua’s death. Only more hurt, sadness and frustration.

The outcome of the hearing last week was that the NMC panel decided that there was insufficient evidence to take one of the cases forward. The hearing for the other case will recommence at a future date. Three more hearings relating to Joshua’s death are due to take place around May.

They NMC should put an end to all of them. None of the staff involved in the care of my wife and son wanted the outcome to be the horrific death Joshua suffered. The real wrong doing relating to Joshua’s loss wasn’t the mistakes that led this death, it was the attempts to conceal the truth about what happened and the dishonesty that my family have had to endure. Yet ‘dishonestly’ or ‘covering up’ doesn’t feature on the list of ‘allegations’, which more than 7 years later, the NMC have decided to pursue.

Over the past 7 years, I have lived and breathed a system that simply doesn’t work. I see the same sad themes emerging from other tragic cases I come across. Families broken twice. Firstly, by the avoidable loss of a loved one and then broken again by a system that denies them answers and instead sends them down a torturous route of complaints processes, data protection requests and legal proceedings which suck energy, time, emotion, resources and achieve little change.

Healthcare is complex. From to time, those working within it will make mistakes… ‘to err is human’. Systems and processes should be designed and in place to minimise the chance of human error leading to harm, but when something as tragic as an avoidable death does occur, there can be no excuse for not doing everything possible to investigate, understand what happened and ensure lessons are learned to safeguard others.

To break the cycle of failing to learn, we must have a culture where healthcare professionals feel safe, confident and supported in being open and honest about errors and mistakes. This must never translate into a lack of accountability where there is recklessness or covering up, but rather it must translate into a step change in the way the healthcare system views mistakes and invests in the resources and skills needs to look deeply enough at the causes of error to ensure the right lessons are learned.

One the most powerful talks of the Global Patient Safety Summit last week came from Don Berwick who said that all healthcare systems have to choose between ‘fear or safety’ – that it isn’t possible for both to coexist.

Last week my wife and I experienced the very worst of what a system preoccupied with blame can look like.  What was such a sad week personally, was brightened by a very strong message of hope for the future. The measures announced by the Health Secretary last week are about the NHS choosing ‘safety’ and not ‘fear’ and I welcome them wholeheartedly. I share the sentiment of Scott Morrish in his powerful and moving piece in the Times last week. These measures are important steps that will help support the change in culture that the NHS so obviously still needs to make.

 

James Titcombe – March 16th 2016

 

Thoughts on the National Maternity Review

Last week saw the long awaited publication of the National Maternity Review (NMR). The review was announced by NHS England in early March 2015, shortly after the publication of the Morecambe Bay Investigation report. I was delighted to have been asked to join the review panel. After all the horrors of the events at Morecambe Bay, this seemed like great opportunity to influence something with the potential to make a real difference.

I was a panel member of the NMR until September 2015, when I took a decision to step down. I’m not going to go over the details of that decision again now, other than to say that for me, it was necessary and the right thing to do. After I left, some very positive things happened. Janet Scott from Sands was invited to take my place on the panel (someone whom I admire and respect) and Bill Kirkup was asked to join the main panel as well as lead some work looking at the variation in the quality and safety of maternity services across the system. In addition, with Janet’s help, the maternity review team were able to arrange a series of engagement events for parents affected by poor maternity care, which I felt was incredibly important.

Before going any further, I should say clearly that I think the NMR has a made some good, important recommendations. I am going to come on to these a little later.

Firstly though, I need to talk about the areas of most concern and disappointment.

Personal Maternity Budgets 

Not surprisingly, the headlines following the publication of the maternity review have focused on the proposal for pregnant women to be given £3,000 ‘personal budgets’ so that they can commission their own maternity care.

This recommendation has, rightly in my view, caused much concern.

Questions have been raised that this recommendation is ‘nothing more than a pretext for privatisation’ and risks leading to greater fragmentation of services.

Other media reports have raised concerns that this recommendation is part of a clear agenda of pushing more community births. Jane Merrick of the independent writes.

Most worrying of all is the clear agenda that the NMR, like the wider medical profession, has in favour of home births. The Cumberlege report is explicit: “This report envisages more births taking place in the community, ie in midwifery care and at home… As a result, there may be lower demand for obstetric services.”

The article asks the question, “Is this the choice that mothers really want?”

This seems like an important question.

I write as the father of three children, one of whom sadly is not with us as a consequence of serious failures in maternity care.  What our family needed more than anything else was a good, safe local service that prioritised a safe outcome. The NMR itself is clear that home birth is an option only 10% of women choose, so where has this recommendation come from?

Just weeks after the NMR was announced, an email was distributed to all of the panel members containing the details of this proposal, with some excited words of endorsement from the review Chair. During my time on the panel (from March to September 2015) there were no detailed discussions about the proposal. It became very clear to me that this was a pre-determined recommendation of the review, a ‘must have’ agreed somewhere, before the review had even started.

I do think that this is an important point. Holding an independent review that looks at evidence, identifies issues and areas that require improvement and through discussion and engagement, develops proposals aimed at addressing identified issues, is surely the right way in which recommendations of major national reviews should be arrived at. The recommendation regarding personal maternity budgets was not arrived at as a result of such a process. I think there is a need for openness and honesty around this point.

Given all of this, the final comments in Jane Merrick’s article are worrying.

“Clearly this is about money: it costs the NHS £600 more if a woman gives birth in hospital than at home. The NHS budget is under strain, but why should mothers put up with all the pain and risk to their unborn child as a way to save money?”

Stark Findings

The headlines focusing on the personal budget proposals have detracted from some really stark findings of the NMR. Dr Kirkup’s section of the report on safety includes the following observations.

  • That half of all term, singleton, normally formed antepartum stillbirths had a least one element of care that required improvement and involved missed opportunities that could have saved the babies life. Only a quarter of these cases were subject to an internal review and the quality of these was ‘highly variable’. (MBRRACE Perinatal Confidential Enquiry Report 2015).
  • Nearly half of CQC inspections of maternity services had safety assessments either inadequate or requiring improvement.
  • That it is clear that there is widespread ‘under-reporting of safety incidents’ in maternity services.

Importantly, the review concludes that the variation in outcomes across the country was evident, even after adjustment for the effects deprivation and maternal age. The report found

“…the otherwise unexplained variation is likely to be associated with differences in the effectiveness of care.”

These stark findings show that too often babies are dying for avoidable reasons and that currently, the NHS often doesn’t learn from these tragedies. These findings are hard to reconcile with NHS England’s statement when the report was published.

“…the independent review finds that the quality and safety of NHS maternity services has improved substantially over the past decade.”

 Whilst it may be true to say that outcomes have improved overall, there is clearly much scope for improvement and the gaps between good and bad (in outcomes and in investigating and learning) are still much too large.

 At Morecambe Bay, between 2004 to 2013, 11 babies and a mother died in what Dr Kirkup described as a ‘lethal combination of failures’ at every level in the system.

It is important to reflect that the truth about events at Morecambe Bay only emerged after a detailed investigation and that the data didn’t indicate that there were any problems (in fact the trust referred to the official data on perinatal mortality to claim that the hospital where my son died was one of the safest in the country).

One of the most important lessons from the Morecambe Bay Investigation is that the data we do currently collect relating to safety really isn’t a very reliable indication of what is happening on the ground.  Indeed, the NMR itself acknowledges this, finding that:

  •  outcomes for 10% of births were missing from the official statistical data (HSCIC Hospital Episodes Statistics), and
  •  Perinatal deaths are themselves subject to inconsistency of data collection.

Place of birth

 The NMR includes an evidence review by the National Perinatal Epidemiology Unit (NPEU) which covers ‘safety of the place of birth’. This section gives an overview of the birthplace study (https://www.npeu.ox.ac.uk/birthplace ) and NICE clinical guideline 190: Intrapartum care for healthy woman and babies.

The NMR says that there is no evidence that outcomes are worse for women planning their second or subsequent birth at home or in a midwifery unit, but that for first births the position is different – there is a higher risk of transfer and with home births a small increased chance of an adverse outcome for the baby

However, concerns have been raised about the validity of birthplace study and NICE guideline 190.

Professor Brian Toft OBE, Emeritus Professor of Patient Safety at Coventry University and patron of the Birth Trauma Association and Action against Medical Accidents (AvMA) has warned that advice in the revised NICE guideline could be dangerous for both mothers and babies.

“At present there is no robust evidence to justify NICE assuring low risk first time mothers that to give birth in a free standing midwifery unit is as safe as in a hospital. Indeed, there is evidence to suggest the contrary…Consequently, given the potential harm to which mothers and their babies would be exposed, if the assertion by NICE should prove to be wrong; the weight of evidence in favour of such a change in public policy ought to be irrefutable.”

Given that the review supports the expansion of community births, the lack of robustness regarding the evidence is concerning and the need for caution and careful monitoring and evaluation of future changes cannot be overstated.

Litigation culture, better investigations and a rapid resolution and redress scheme

As already mentioned, the NMR does make some good recommendations for positive change. But there are many areas where I think the report gets it messages confused.

The report states

“Professionals… told us that the threat of litigation and the high costs associated with it could encourage obstetricians and midwives to practise in a risk-averse way..”

 This statement reads as though ‘litigation’ itself is the problem in its own right, but of course, litigation doesn’t occur unless a baby or mother is harmed or lost in childbirth (and where different care could have avoided the outcome). In relation to the avoidable harm or loss of mothers and babies, surely being ‘risk-adverse’ is exactly what we want midwives and doctors to be?

The report goes on

“The litigation process caused them considerable stress and it inhibited the clinicians from discussing openly what had gone wrong, and by needing to involve legal representative, the process took longer to resolve, often many years.”

 The report makes a recommendation that for there should be a standardised investigation process when things go wrong “…to get to the bottom of what went wrong and why and how future services can be improved as a consequence”. An almost identical recommendation was made in Morecambe Bay Investigation report published almost a year earlier.

The maternity report also recommends a ‘rapid resolution and redress scheme’ which in certain cases (the report suggests the scheme is limited to harm caused to babies born at 37 weeks or after), would give a family an alternative means of seeking redress outside the tort litigation system.

The thinking behind this recommendation comes from the model of insurance that exists in Sweden. This ‘no blame’ insurance based system has been in place since 1975, but Sweden has only seen a dramatic decrease (50%) in avoidable serious birth injuries in the past 6-7 years. This corresponds, and is attributed to a scheme called ‘project safe care delivery’, in which the insurance service itself supports high quality multidisciplinary peer review and the implementation of measures to prevent the causal factors being repeated following adverse incidents that lead to claims.

It isn’t clear to me that the NMR recommendation has been well thought through. High quality investigations are needed in response to ALL serious incidents in maternity, and given that the tort legal system and the NHSLA will continue to exist, I’m not sure how the ‘rapid resolution and redress scheme’ will solve the problem of organisational defensiveness which the litigation system is clearly currently a major part of.

The Swedish system has been successful because the insurance system itself contributes to and actively supports a learning culture. The NHSLA currently weight their premium calculations on the claims history of the organisation and don’t take any account of whether or not the organisation has properly reviewed and learned from what happened.

In order for the maternity review’s ‘rapid resolution and redress scheme’ to effect a real change in behaviour, something else is needed. For example, the NHSLA could be taken out of the equation by ensuring that investigations under the scheme were carried out in a ‘protected space’, the findings of which would not be admissible for a civil claim.  Even so, the need for any such investigation to share factual information with the family involved and adhere to the Duty of Candour, would raise real questions about how far any such ‘protection’ could extend.

The example of Sweden shows that in the long term, it has to be in the overall interests of any national healthcare insurance/litigation system to incentivise early high quality, open and honest investigations that lead to action being taken to reduce the chance of reoccurrence. It’s unacceptable that the way the NHSLA currently operates pulls in the opposite direction.

In failing to make any recommendation for change aimed at the NHSLA, the NMR in my view has missed an opportunity.

The real lessons from Morecambe Bay

The Morecambe Bay Investigation report shone a spotlight on one particular service over a near 10-year period. The maternity unit at Furness General Hospital was not a statistical outlier, a look at the data alone would have only provided reassurance that the unit was safe. But of course, what Dr Kirkup found was a very different picture.

Fundamentally, many of the avoidable outcomes at Morecambe Bay were caused by midwives pursuing an ideology of ‘normal birth’ at the expense of safety and poor working relationships between midwives and obstetricians. The NMR itself confirms that these were themes it found during the review.

we…heard about a culture of silo working and a lack of respect across disciplines, particular between obstetricians and midwives.”

 In many ways, the necessary lessons from Morecambe Bay are encapsulated by the experience at Southmead Obstetric led maternity unit, where Tim Draycot has led work that has achieved an incredible improvement in outcomes. The NMR highlights these achievements, which include.

  •  A 50% reduction on babies born with a low Apgar score
  • A 45% reduction in school age cerebral palsy
  • A 100% reduction in permanent brachial plexus injury after shoulder dystocia
  • A 91% reduction in litigation claims

How has this been achieved? Rather than silo working, midwives and doctors train and work together as one team. Rather than midwives acting to keep doctors away in pursuit of a normality agenda, at Southmead doctors and midwives simulate obstetric emergencies and fine tune working together, to recognise when problems develop and respond effectively.

If this can be achieved at Southmead, it must be possible to achieve similar results elsewhere.

Many of the recommendation in the NMR are clearly intended to help achieve exactly this, but there must be a real concern that the agenda for more community births and personal maternity budget proposals risk pulling in a very different direction.

How will different services, including independent midwives completing for pregnant women’s custom, help improve trust and working relationships between midwives and obstetricians?  How can we ensure pregnant women and their families are given accurate and unbiased information about risk and choices given this competition for custom? How can we be sure that pursuing a national policy of increasing community births is really safe, given the lack of consensus about the robustness of the evidence used to support these changes?

Changing culture in an organisation as large of the NHS is hard. When the whole system isn’t aligned, levers and incentives can pull in different directions. The NMR should have been an opportunity at a national level, to ensure the overall system lines up to make it easy for the right changes, culture  and behaviours to flourish.

Whilst there are clearly many good recommendations with the potential to make a difference, my concern is that NMR has left some big gaps and that the central push to expand community births and create personal health budgets, risks detracting from the many sensible and positive recommendations made.

In an article published in HJS today, Bill Kirkup warns that the lack of progress since the Morecambe Bay Investigation report (published a year ago this week), ‘risks disaster’. Dr Kirkup states that there has been ‘no visible action in some areas’ and that ‘..it would be wrong to suppose the National Maternity Review was a response to the Morecambe Bay investigation.’

I can only echo Dr Kirkup’s comments and hope that in the months ahead, we see some rapid progress in the implementation of the recommendations of his report.

 

James Titcombe – 2nd March 2016