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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.

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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.

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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

 

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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

 

 

 

 

Thoughts on the junior doctors dispute…

I’ve watched the junior doctors contract debate unfold with sadness, dismay and a sense of frustration. Improving the quality and consistency of NHS care across all days of the week is a laudable aim that both NHS staff and patients support. So why has this debate become so polarised and acrimonious?

The BMA have accused Hunt of smearing junior doctors, misrepresenting academic studies and singling out junior doctors as the cause of excess weekend mortality. They have argued that the new contract is unsafe and that delivering a seven day service with existing numbers of staff will stretch services further and impact on the safety of weekday services. The mantra from the BMA has been that junior doctors already work seven days and to imply that they don’t undermines their professionalism and is a slur against their dedication to their patients.

These arguments are difficult to reconcile with either a considered read of the new contract proposals or the context in which the dispute has taken place. Whilst there is always a danger in the interpretation of studies (no doubt there are some big lessons here for the government), these arguments miss the point: no one disputes that there is now clear evidence that mortality rates for patients admitted to hospitals are higher at weekends. It would surely be wrong for any government aware of this not to act. However, the claim that junior doctors have been singled out as being solely responsible simply isn’t the case. To quote Bruce Keogh:

“The issue is complex with no single causative factor or solution. To tackle the problem we have developed 10 clinical standards, based on evidence and consensus. They seek to improve the availability of diagnostic tests at weekends, the availability of senior doctors to interpret and act on those tests and the provision of support services to enable the right treatment in a timely fashion. So this is not just about doctors, it is about teams and facilities.”

If the government strategy to improve weekend care was solely based on a new junior doctors contract, the BMA would be right to view this as cynical and unworkable, but this is evidently not the case. The contract changes for junior doctors are just part of a range of changes needed.

Similarly, it is hard to reconcile claims by the BMA that the new contract is unsafe with any considered view of the contract itself. The new contract reduces the maximum hours junior doctors are permitted to work and therefore provides more protection for patients against the risks of over-tired doctors than currently is the case.

The government’s chief negotiator, Sir David Dalton has recently said that commentary on social media has been ‘unhelpful’ during the negotiations. With comments such as “…we won’t let patient safety come crashing to the ground” tweeted from the BMA’s official Twitter account, it’s easy to understand his point. Is it really feasible that someone with Sir David’s reputation for safety would support a contract that increased risks for patients?

Similarly, saying over and over again that junior doctors already work seven days a week also misses the point. Of course junior doctors already work some weekends: the issue is one of system design. No one would design from scratch a seven day service with a large differential in pay rates on certain days. It is far better to remove adverse system incentives by reducing this differential, compensating with an increase in overall pay rates across all days.

Another argument often heard is that trying to achieve a seven days service with existing staff will impact on weekday services. But is the situation really this simple? A seven day NHS will still care for and treat the same number of patients but will be able to do so closer to their point of need. More patients admitted over a weekend will receive the diagnostic tests and treatment nearer the time of admission, meaning earlier discharges, less pressure and demand during the week and no backlog clogging up the system on Mondays.

There is currently understandable concern about financial pressure and the impact on safe staffing levels. The government’s decision to shelve the NICE work on safe staffing has only added to this, but again, the situation is not straightforward. The contact time staff have with patients is also important and the government are right to look at how this can be improved in the context of safe staffing overall

Largely as a consequence of reforms this government have implemented, there are now far fewer hiding places for unsafe care. There has been a push for more data and transparency regarding staffing levels, as well as changes to increase the independence and robustness of regulation. This includes a major focus during CQC inspections on ensuring that staffing levels and skill mix meets the needs of patients. In addition, the government has supported the establishment of a new independent patient safety investigations body which, when operational, would highlight staffing issues if they were contributory factors in the patient safety issues under investigation.

These are not changes that a government disingenuous about patient safety would make. As a consequence of its own reforms, any significant trend in adverse outcomes relating to inadequate staffing levels will now be more visible than ever before. If the strategy was to squeeze staffing to below safe levels these changes would make no sense. It would be akin to trying to encourage motorists to speed whilst simultaneously increasing the number of speed cameras

So how have we got here? It is in my view telling that David Dalton said in a recent HSJ interview that “…the BMA was not serious about negotiating a deal.” Do we now call Sir David’s integrity into question as well as Hunt’s, or could there actually be some truth in what he is saying?

The negotiations have been taking place at a time when morale in the NHS in low. Junior doctors are bright, hardworking people who chose a career in medicine because of a desire to save lives and make a difference. We need a system that nurtures and properly rewards them. If the currently system is failing to do this more needs to be done. But surely the junior doctor’s contract is the wrong battle, fought for the wrong reasons

Over the weekend a doctor sent me a direct message on Twitter which read

“I don’t understand the contract antipathy but very difficult to speak out against. I think very few have actually studied the offers.”

My fear is that the ‘offer’ itself ceased being the central issue in this fight some time ago.
In a recent Twitter exchange, the issue of junior doctors referring to their intellect during discussions came up. One junior doctor commented

“…I can’t apologise for having excelled academically no more than a sprinter should for being good.”

And of course, no junior doctor should have to. The challenges to improving patient safety and culture within the NHS remain huge. Too often still, the NHS responds to avoidable harm defensively and in a culture where the prevailing emotion is fear. The consequences of this are that the same mistakes are sometimes repeated and learning doesn’t happen, or when it does, those lessons are confined locally and not shared across the system. The NHS has an unfortunate history of burying its bad news, rather than facing up to problems and taking action to make things better.

To quote Bruce Keogh again:

“The transparent provision of data and information to the public is one of our strongest drivers for promoting quality in healthcare. But the use of data to promote quality also exposes some inconvenient truths.”

The only way we stand a chance of truly making lasting change is if patients, politicians and NHS staff work together. We must never go back to the days of burying inconvenient truths. The energy, passion and intellect of junior doctors are badly needed if these challenges are going to be overcome.

Johann Malawana recently tweeted

“…If NHS leaders…don’t value juniors & support imposition there are consequences.”

It would be tragic if these ‘consequences’ included yet more disruption for vulnerable patients and the derailment of further much needed changes to improve patient safety and save lives.

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Reflections on 2015

2015 has been a busy year for patient safety in the NHS

In March, the Morecambe Bay Investigation report was published.

The report marked the end of 6 years of effort by a number of families to understand how the failures at the maternity unit at Furness General Hospital (FGH) occurred, why they went unaddressed for so long and why so many lives were lost as a consequence.

In July, the government published its response to the Kirkup report, alongside its response to the Freedom to Speak up Review and the Public Administration Select Committee report ‘Investigating Clinical Incidents in the NHS. The response accepted all the Kirkup report’s recommendations.

2016 will see the publication of the Royal College of Obstetricians and Gynecologists (RCOG) ‘Each Baby Counts’ project. I am sure this important work will add to the momentum for improvements in the safety of maternity services. I am also encouraged by the announcement made by the government in November pledging to half the number or avoidable baby deaths in England.

The publication of NHS England’s National Maternity review is also expected in early 2016 and all in all, 2016 looks set to be an important year for maternity services with the need to improve safety and reduce avoidable harm high on the national agenda.

How the NHS responds to avoidable harm

One of the most powerful articles I read in 2015 was this piece from the patient safety correspondent at HSJ, Shaun Lintern.

The article highlights three examples of the experience of families affected by the avoidable loss of a loved one due to poor care.

Shaun wrote

“…rather than show them some humility and compassion, the NHS hurts them all over again. It is quite simply unspeakably cruel. Some positive steps have been taken towards a more open and transparent NHS, but so far these have relied on new regulation, beefed up codes of conduct and, as a last resort, new laws and threats of prosecution. The cultural change needed in the NHS will require a personal determination to act differently by everyone from frontline staff to individuals in system leadership roles.”

Shaun highlights that the three examples in his article are the tip of the iceberg and I am in complete agreement with him. 2016 must be a year of meaningful and lasting change.

Just weeks ago, the country was shocked by a report which looked at the deaths of people with a Learning Disability or a Mental Health problem in contact with Southern Health NHS Foundation Trust, between April 2011 to March 2015.

The report was sparked by the preventable death of Connor Sparrowhawk in July 2013. The agony for Connor’s family has been made so much worse by the way the trust responded to the appalling events that led to Connor’s unnecessary death. Now, largely thanks to the courage and determination of Connor’s family – a truth has emerged that clearly shows failures to investigate and learn from such events go far wider that Connor’s loss alone.

Healthcare is complex and we all must accept that from time to time, those working within it will make mistakes. 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.

The NHS and the principles it was founded on are rightly something our country should be proud of. In 2015, I experienced my father having to call an ambulance following chest pains. The ambulance arrived within 10 minutes, he was taken to A&E, given all appropriate tests and kept overnight in an immaculate ward, with kind and caring staff until given the all clear to go home the following day. He’s since had follow up outpatient’s appointments and has received an exemplary standard of care.

When I reflect on the short life and death of Joshua, after he collapsed at Furness General Hospital, the care he received in Manchester and later Newcastle, was second to none. During the 7 days Joshua spent at Newcastle, my wife and I witnessed the lives of other babies, some born with serious heart defects, being saved by truly remarkable people doing remarkable work. Those same staff came so close to saving Joshua’s life too.

We should celebrate and be proud that we have an NHS that at its best, provides world class, life-saving care to all. But however good the NHS can be, we should never accept variation in the quality of care such that for some people at some times, care is unsafe. Neither should we hold the NHS with so much reverence that we become blind and unwilling to acknowledge its problems.

The undeniable truth, however uncomfortable it may be, is that across the NHS as a whole there remains considerable variation in how safe the provision of care is. For all its strengths, the NHS is still way behind the kind of safety culture that exists in other high risk sectors and the truth is, as Shaun Lintern’s article so powerfully highlights, too often the way the NHS responds to mistakes and avoidable harm leads to further suffering for families and means that learning simply doesn’t happen.

The direction of travel

Facing up to these issues is a real challenge, both for the many dedicated professionals who work in the NHS day in day out but also for politicians of the day. In the past, former Secretaries of State for Health have described a need to maintain public confidence in the NHS and the Department of Health has been accused of acting like a ‘denial machine’ .

Certainly this echoes my experience following my son’s death in November 2008 and facing obfuscation in trying to establish what happened, followed by system wide denial that there were serious risks to mothers and babies at FGH until much too late.

Over the past few years the direction of travel has shifted markedly. There has been a real drive to improve transparency, both through a more robust and independent regulatory system, new laws around openness and candour and national movements like Sign up to Safety, which support individual healthcare providers to develop safety improvement plans aimed at reducing avoidable harm.

There is a long way to go but the NHS is already in a different place to where it was just a few years ago. A consequence of these changes is undoubtedly an increased awareness of the problems with variation, both in quality and safety and the deep rooted cultural issues that clearly exist. We must not conflate this increase in awareness with a belief that things have suddenly got worse. If we are to have any hope of making lasting change, we need to start by being honest about where we have come from and where we need to get to.

I do think that it’s right (as someone who has voted Labour in the past) to acknowledge that the current Secretary of State for Health has probably done more than any other Health Minister in history to prioritise reforms in the interests of patient safety.

2016 now looks set to be a hugely important year for the NHS and patient safety. In April, a new national patient safety investigations body will be set up. No other healthcare system in the world has an equivalent body. The new National Freedom to Speak Up Guardian  will be set up with local ‘speak up’ guardians in every provider organisation supporting staff to raise any concerns about safety in a safe environment .

The NHS has been described as a ‘supertanker’ and whilst these measures by themselves will not turn things around overnight, they are part of number of incremental steps that have a potential to make a real difference.

2016 will also see the merger of the TDA and Monitor (together with the safety functions that currently sit within NHS England) into NHS Improvement. All eyes will be on this new organisation and how it will work within the system to most effectively support organisations to improve.

Further Hopes for 2016

There is an urgent need to transform the way the NHS responds and learns from avoidable harm. The new patient safety investigations body has the potential to make a big difference, but it can only be part of the solution. Ombudsman reform, commitment from individual organisations, the litigation system and regulation all must pull in the same direction to support change. Central to this is ensuring that staff who make genuine mistakes always feel safe to report and be open and honest about them. Families affected by avoidable harm should always be treated with compassion and care. The science of Human Factors is fundamental (click here for one of best articles of 2015 about Human Factors and healthcare).

2015 has seen some difficult tensions between the Department of Health and the BMA over proposed changes to the junior doctor’s contract. This dispute has the potential to detract from other important issues where the focus needs to be. There is a strong case for strengthening 24/7 provision in our hospitals. There have been a number of studies in the last 5 years pointing to a ‘weekend effect’.  Whilst it is clear that many dedicated doctors and other NHS staff already work at weekends, the current system can make  it hard and expensive for trusts to properly organise and rota their  staff across 7 days. As Bruce Keogh has said, the current system operates on good will, rather than good design. In the interests of patients, I hope that in early 2016, the BMA will work to reach a fair agreement over changes to the junior doctor’s contract through negotiation and that strike action can be avoided.

Some thanks….

In December, my book ‘Joshua’s Story’ was published. A huge thanks again to everyone mentioned in the acknowledgments of the book, especially to Murray Anderson-Wallace, Anne Wallace and Roland Denning for all their help and hard work. I am hugely indebted to Phil Hammond, Peter Walsh, Jenni Middleton and Shaun Lintern for their support. The response to the book has been lovely and receiving positive feedback has meant so much.

A huge thanks and congratulations to Martin Bromiley on being recognised in the Queens New Years Honours list. Martin is one of the most inspiration people I’ve ever met and his recognition could not be more deserved.

Finally, thanks to all the many people, patients, campaigners, NHS staff, academics, civil servants and politicians who are all working hard to bring about much needed change and improvements in patient safety.

Wishing everyone a happy New Year and hoping that 2016 brings about further much needed changes and improvements in patient safety.

 

James Titcombe

January 2016

 

 

 

 

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Joshua’s Story – Book launch – 2nd December 2015

7 years ago my wife and I should have been looking forward to a Christmas with our new baby son, but the reality was very different. Joshua had died in what can only be described as horrific circumstances and we were struggling to carry on with our lives with any sense of normality.

Joshua’s short life and death is a story of both a shocking absence of basic care, but also of world class care from some of the most dedicated and professional people I’ve ever met. Joshua – we all – experienced extraordinary care from Dr Jane Cassidy and an amazing team of consultants and nurses at the Freeman Hospital, Newcastle. Over the years, I’ve stayed in touch with Jane who now works in Birmingham Children’s Hospital – a place that exemplifies the very best of the NHS – where amazing work to save and improve lives goes on every day.

As well as the catastrophic failures in care at Furness General Hospital, my family and I will never forget the excellent, compassionate care that Joshua received in the days before he died.

Joshua’s loss was devastating, but, as anyone who reads “Joshua’s Story” will find out, it is the events that followed – the obfuscation, dishonestly and covering up – that ultimately meant lessons were not learnt and that mothers and babies at FGH maternity unit were exposed to serious risks for far too long.

Indeed, the closing of ranks was so strong, with almost every organisation failing to take appropriate action, that there were many times during the last 7 years that it really did look like the full truth about what happened would remain hidden.

However, some exceptional people went against the tide at key moments and provided support that made all the difference.

I would just like to mention some of those people now.

First was Christina McKenzie, at the time Head of Midwifery at the Nursing and Midwifery Council.

After the first review of the LSA report – which was a complete whitewash – it really did feel like the whole system had closed ranks and I thought that I would never overcome the barriers that it seemed were being constructed in front of us.  

I remember having a phone call with Christina and feeling like it was such a breath of fresh air.

Christina played a key role in ensuring there was a second review of Joshua’s LSA report which eventually exposed serious flaws in the process and findings.

Then there was Detective Chief Inspector Doug Marshall

The Police originally refused to investigate Joshua’s death – but in early 2011, I met with DCI Doug Marshall and that changed everything. When I first met Doug, I expected the same scepticism that I’d become so used to – but this conversation was different. Rather than assuming that I was an angry and grief stricken Dad and therefore unreliable or exaggerating, Doug actually listened and took what I said seriously. Cumbria Police subsequently opened an investigation at a time when every other organisation had pretty much turned a blind eye. It was the opening of the Police investigation that led to other families coming forward and the full scale of what had gone wrong at Furness General Hospital began to emerge.

After the Police investigation had finished, I met with Doug. He told me a very personal story that he has given me permission to share. Doug lost a baby boy – Andrew James Marshall died on 6th September 1991 – due to avoidable failures in his care. I think Doug’s love for his son and the insights he had from his own experience may well have been the critical factor in the whole journey described in Joshua’s Story.

There are many other professionals who at key moments provided critical support. Throughout even the darkest times, there were people inside the trust at Morecambe Bay who sent me private messages of support and encouragement. Our legal team at Burnett’s solicitors – whose support and help was mostly provided on a pro-bono basis – were excellent. They engaged Paula Sparks, an excellent barrister – who again provided her expert services and support completely free of charge.

There is no doubt in my mind that this support helped ensure that Joshua’s inquest, which took place nearly 3 years after his death – had such a significant impact and triggered the regulatory response and actions that followed.

I’m afraid that there are so many people that I need to thank that I simply couldn’t hope to acknowledge everyone here, but I will try and mention just a few more.

I’m grateful to my local MP John Woodcock for strongly supporting our calls for an investigation. Shaun Lintern, for his superb investigative journalism that helped maintain a national focus on the issues at Morecambe Bay and of course, to Dr Phil Hammond for all his support and brilliant articles in Private Eye.

I would like to thank Action against Medical Accidents (AvMA), especially Peter Walsh for his invaluable support and advice. I am so proud to now be a Patron of AvMA, an organisation that continues to campaign for patient safety and justice, supporting and advising numerous families who find themselves in the unfortunately position that my family and I found ourselves in November 2008.

I must say a big thank you to Dr Bill Kirkup and the investigation team for carrying out such a robust and credible investigation. Their professionalism was outstanding.

A special thanks is owed to my close friend Helen Hughes for all her encouragement (or I could say nagging!) without which I would never have had the discipline to sit down and write this book. I must say a big thanks to Murray Anderson-Wallace, Anne Wallace and Roland Denning for the superb job they have done editing, producing and publishing the book and organising today.

I must also thank Jonathan Hazan and Datix for their generous sponsorship of this evening

My biggest thanks however must go to the other families affected by events at Morecambe Bay, especially Liza Brady and Simon Davey who lost their little boy Alex in September 2008 and Carl Hendrickson who tragically lost his wife Nittaya and his baby boy Chester due to serious failures in their care in July 2008. Without the support of Liza, Simon and Carl, the truth about events at Morecambe Bay would never have emerged.

I won’t talk for too much longer, but I would like to say just a little about patient safety nationally. For the past 2 years I’ve been working in a role at the Care Quality Commission (CQC), an organisation that for good reasons is heavily criticised in Joshua’s Story. I’m genuinely proud of the changes that I’ve seen at CQC and the difference I know that regulation makes for patients and people who use services. There is still a long way to go, but I am genuinely optimistic about the direction of travel. As a member of the expert advisory group for the new Independent Patient Safety Investigation body for the NHS, working alongside Mike Durkin and many others patients, clinicians and safety experts, including inspirational people like Martin Bromiley who has done such incredible work through the Clinical Human Factors Group (CHFG). I think we have a once in a generation opportunity to change the way the NHS learns from avoidable harm.

I don’t think there has ever been a time when patient safety has had such a high priority at a national level. I’m grateful to the current Secretary of State for Health, Jeremy Hunt for helping to drive and sustain this focus – and for the personal kindness and support he has shown me over the years.

I can’t help but feel proud that Joshua’s Story has brought so many fantastic people together in one place. High profile clinicians and managers in the NHS but also some incredible families, who just like me, have suffered avoidable loss or harm of a loved one and are now on their own difficult journey to make sense of what happened and ensure the legacy of their loss is learning and lasting change.

Rolf Dalhaug lost his baby son Thor in September 2013.

Michelle Hemmington lost her baby son Louie in May 2011.

Nicky Lyon lost her son Harry in November 2009.

Joanne Hughes lost her daughter Jasmin in February 2011.

Scott Morrish lost his little boy Sam in December 2010.

Rhiannon Davies and Richard Stanton lost their daughter Kate in March 2009.

Deb Hezeldine lost her mum Ellen in 2006.

These are truly inspiring families who have suffered appalling tragedies and have done incredible work to seek learning and change. In many cases their journeys have been made so much harder and more distressing than they needed to be – often due to similar themes to those echoed in Joshua’s Story.

All of you are leaders.

Just as there were key people in Joshua’s Story that made all the difference, I believe that each and every person that works in the NHS can make a difference too. We all need to work together to build a culture where staff feel safe to do so. I hope that Joshua’s Story and this event today will help ensure that conversations continue about doing exactly this.

Thanks so much again to everyone for coming tonight

 

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Voices that need to be heard

I’m aware that I talk about Joshua in my blogs and on Twitter a lot – perhaps too often. Many people now know his story and most know what happened at Morecambe Bay. Joshua’s death is only one of a large number of avoidable deaths caused by serious failures in care at the hospital where he was born and just one of hundreds of avoidable deaths that happen in maternity units across the NHS each year. So this blog isn’t about Joshua (he won’t be mentioned again), instead I want to write more in general terms about the experience of loss due to failures in maternity care, what I’ve learned from meeting other families and what I’ve learned about how the NHS responds.

 Just this week, HSJ reported on the tragic case of baby Kate Stanton-Davies. You can read the full HSJ report here. Some of the most difficult and upsetting aspects to this tragic case include the following:

 Kate’s mother was wrongly classified as ‘low risk’ and not given a choice of where to deliver Kate

 A failure to follow guidelines and best practice

 Poor quality records, retrospective completion of clinical notes and conflicting accounts of events

 An investigation by the Local Supervisory Authority that was ‘not fit for purpose’ and included ‘multiple  inaccuracies’

 The trust’s ‘inappropriate reliance’ on this flawed report meant it had delayed accepting failures had  occurred and could not be assured lessons had been learnt.

 The supervisory report referred to baby Kate as ‘it’.

 Although baby Kate tragically died in march 2009, a proper investigation in order to learn lessons is only just being established now, more than 6 years later. What is most shocking of all is the absolute certainly that were in not for the extreme tenacity and courage of Kate’s parents, a proper investigation wouldn’t be happening at all. 

 The reality of losing a baby is a life changing event, merely getting back to some sense of routine can feel almost impossible. Very few bereaved families also have the strength to battle with the system in the way that baby Kate’s mum and dad have been able to. For every case like Kate’s where the extent of failures and coverup are eventually exposed due to super human efforts of families, there must be 100’s of other cases that are swept under the carpet.

 In recent years, I’ve personally met several families who have contacted me following similar circumstances. Every experience is different, but over time some common themes have become clear to me, these include:

 A sense that the focus of their maternity care was on ‘experience’ and achieving ‘normal’ birth and not on safety

 That their own concerns about what was happening weren’t listened to or acted on

 A failure to recognise and act on signs that indicated that there might be a problem developing sooner

 That following the tragic outcome, the system responded defensively and with hostility

 I have recently heard about a case where a senior manager instructed a clinician to omit key information from a serious incident report because of concerns about ‘how it would be perceived’. 

 Out of desperation, many families who feel that the trust and staff involved haven’t been open and honest with them turn to the legal system which can be drawn out and even more defensive. Sometimes families only gain an acceptance of serious failure years later, meaning lessons from what happened either don’t happen at all or happen much too late. To make this situation worse, families are still being told by the Health Service Ombudsman that they ‘…would not be able to consider their complaint whilst legal proceedings are ongoing’, meaning families who are told this effectively have their right to appeal the trust’s response to their compliant removed. 

 Families who lose babies due to failures in maternity care are often traumatised as well as grief stricken. Their trust in healthcare professionals is understandably shattered, but rather than acting to restore this trust through a caring and compassionate approach, more often than not the institutional response is a failure to be open and honest and only serves to deepen this distrust further. 

 Kate’s mum told me ‘I live for the sake of my living daughter, I fight for the sake of my dead daughter, but every day all I really do is exist because of the pain that is so intense as a result of my loss, and everything I continue to have to live through.’

I remain concerned that due to inadequate systems surrounding the reporting and investigation of serous harm and avoidable loss in maternity services, we still don’t have as full an understanding of the variation in quality and safety and the underlying causes as we could. Projects like Each Baby Counts are hugely important, but until this work is complete, one way we can really start to understand where the gaps are is by meeting families who have experienced avoidable harm and loss and listening to their experience and insights. In fact if we don’t do this, aren’t we missing out on one of the richest and most valuable sources of information about safety and quality and how to improve that there is?

When I was a member of the national maternity review panel, I argued that the review should hold some special workshops and focus groups to ensure that it did properly listen to people with recent experience of avoidable loss and harm. My concern was that the regional events run by the maternity review might be quite daunting to many bereaved parents. For example, just going somewhere with other mums with young children and babies can be emotionally hard for someone who has recently lost a baby.

 I was saddened that I wasn’t listened to regarding these issues.

 After I resigned from the maternity review, I was contacted by one bereaved mum who told me about attending a ‘think tank’ event run by the maternity review. She told me that she felt ‘a lone voice’ when trying to talk about safety. The table she was on was mostly maternity professionals and they had to do a group exercise to discuss a scenario where a mum had wanted a homebirth but had been advised by a doctor against it. The mum then went on to have a straightforward birth and a healthy baby but felt ‘regret’ because she hadn’t had the birth experience she wanted. 

 I felt saddened when I heard this. I thought about how that mum must have felt having a conversation with midwifery professionals about sympathy for someone who didn’t get the birth ‘experience’ they wanted, yet had a healthy and perfect baby – the one thing this mum would have given the whole world to change in her own situation. 

 On further reflection, I now realise that this example perfectly illustrates a wider issue across maternity services at the moment; that there is a real tension between an ethos that focuses on ‘experience’ but where risk and safety sometimes feel played down. 

 I have a genuine concern that in some places, a culture has developed where there is so much emphasis on ‘experience’ and ‘protecting normality’, that the occasional avoidable loss or serious harm caused to a baby because of failure to properly assess and manage risk, is seen as a sad, but inevitable aspect of childbirth and the full impact on the family involved isn’t understood or given the weight it should be. 

  In a system that can currently act to make it so hard for the truth about avoidable harm and loss to emerge and lessons to be learned, it seems to me that a good starting point for any  review looking at recommendations for improvement in maternity care should be to reach out and listen to as many people affected by avoidable harm and loss as possible and furthermore, to actively involve such people in the review process and design of solutions. 

If we don’t do this, I feel that there is a real danger that the most important issues will be missed and that the very people who have the biggest stake in wanting to see services improve, those who truly understand the impact of when things go wrong, the voices that we most need to listen to, won’t truly have been heard.