Monthly Archives: March 2015

The Morecambe Bay Investigation report was published on 3rd March. Myself and other families gave our reaction here.

 

After what has undoubtedly been a really difficult 6 years since losing Josh, I feel (and I know other families feel the same), that finally we have a report that reflects the full truth regarding events at Furness General Hospital (FGH). It took a few days for the report to sink in and then, being completely honest, I’ve been surprised at how I’ve felt in the days since. Whilst I’ve certainly felt a sense of relief and vindication, I’ve also felt deeply sad and frustrated. The way organisations like the Health Service Ombudsman have responded has undoubtedly not helped, but I suppose more fundamentally, now we’ve reached some sort of ‘end point’ my family and I are still left without Joshua. The scale of how preventable and unnecessary Joshua’s death was is now more clear than ever before. This only adds to the sense of sadness, that nothing can bring this little boy back.

 


 

The reality is that nothing can now undo what happened. Myself and other families will have to come terms with that. This is painful and hard.

 

The only ‘remedy’ myself and other families now have is to take comfort from the changes the Kirkup report will now hopefully bring about. Looking on the positive side, this week I met with Jackie Daniel (Trust CEO) and Pearse Butler (the recently appointed new Trust Chair).  I couldn’t help but feel impressed by their openness and sincerity. I can’t speak on behalf of other families, but my sense is that the Trust has now fully accepted the report and are determined to do everything possible to learn and continue to improve in response. 

 

In this blog I also want to talk about the response to the Kirkup report from another important group, midwives and midwifery leaders. Before doing so, I wanted to emphasise that I have a great deal of respect for midwives. I think the vast majority of midwives are incredibly caring and hardworking people who go to work with a passion to bring new life into the world and work in the best interests of mothers and babies.

 

However, I also believe that there are some areas in which improvements are needed in the way maternity care in England is currently delivered. Anyone who follows me on Twitter will know that one of my biggest areas of concern is around the ideology of ‘normal birth’. We all form views and opinions based on our experiences. In the very early days following Joshua’s death and after reading about other tragic cases that happened at FGH, I formed a strong view that an over emphasis on achieving ‘normality’ was a factor in some of the events that occurred.  The Kirkup report fully vindicated my views on this, concluding.

 

“…midwifery care in the unit became strongly influenced by a small number of dominant individuals whose over-zealous pursuit of the natural childbirth approach led at times to inappropriate and unsafe care… We…heard distressing accounts of middle-grade obstetricians being strongly discouraged from intervening (or even assessing patients) when it was clear that problems had developed in labour that required obstetric care. We heard that some midwives would “keep other people away, ‘well, we don’t need to tell the doctors, we don’t need to tell our colleagues, we don’t need to tell anybody else that this woman is in the unit, because she’s normal”. Over time, we believe that these incorrect and damaging practices spread to other midwives in the unit, probably quite widely.”

I support Dr Kirkup’s view that “…natural childbirth is a beneficial and worthwhile objective in women at low risk of obstetric complication…”. However, since taking an interest in these issues in recent years, I’ve been really concerned at what I think has become a lack of balance by some in the debate.

For example, I’ve written before about attempts from some midwifery leaders to play down / undermine the risk associated with childbirth. This blog gives the clearest example of this. Surely it’s important not to overstate or understate risks, but to give true and accurate information to people to help them make informed choices?

I’ve also found that even raising the subject of risk in childbirth can result in dismissive responses on social media.

Earlier this week I participated in a #WeMidwives chat during which I raised this letter from a Doctor which was recently published in a national paper.

In response I was accused of ‘bashing MWs’ and ‘retrospective negativity’.

I don’t think either of these comments are fair. The Doctor who wrote this letter states that he reviews notes ‘all over Britain of babies who may have suffered severe brain damage or death at birth’. He says ‘…a recurring pattern is delay by midwives in calling for medical assistance.’ He also refers to the Kirkup report which was published only two weeks ago.  How can reflecting on these issues be ‘retrospective negativity’?

I could also not help but feel disheartened by another online piece I came across this week in which a number of midwifery leaders give their thoughts on the Kirkup report.

Amongst them was this comment.

This concerns me for a number of reasons. Firstly, the notion that ‘protecting normal birth’ is the core function of a midwife is one I really struggle with. Surely the core function of a midwife is to protect mothers and babies? This author also states ‘I have honestly never a met a midwife who compromised safety in the pursuit of ‘normal birth’. So is what happened at Furness General Hospital really just a unique, one off situation?

Certainly other comments suggest so.

But how can midwifery leaders like this be so sure? Should we really be so ready to dismiss concerns like those of Dr Essex so readily? What does other evidence tell us about why avoidable outcomes during childbirth tragically continue to occur?

This is something I have also written about in the past.

Even a quick review of the evidence suggests that the type of problems that occurred at FGH are far from unique. In 2013, NHS Cumbria published an inquiry into all perinatal deaths that occurred county wide in 2010.

 In this single year, the report found 38 perinatal deaths that had avoidable factors or elements of substandard care. Fifteen of these 38 cases were identified as having avoidable factors in relation to referral to a specialist. The report states.

 

“…many of these were a failure by the midwife to refer to an obstetrician in time for an intervention to be made.”

These comments closely echo the findings of Dr Kirkup’s report.

What can we learn from tragic stories we continue to read about in the media like these?

http://www.bbc.co.uk/news/uk-england-essex-30955936

http://www.telegraph.co.uk/news/health/news/9758307/Baby-died-after-midwives-failed-to-call-for-help-during-labour.html

http://www.hulldailymail.co.uk/Mum-awarded-25-000-midwives-8217-mistakes-led/story-26041836-detail/story.html

It is my strong view that it would be a tragic missed opportunity if the general response to Kirkup from the midwifery profession as a whole was to dismiss what happened as a local failure, the lessons from which thought not to be applicable to the wider NHS.

I hope that there will be much more open debate about Kirkup in the future, involving both midwives and doctors. Of course, it remains important that maternity services function to avoid unnecessary interventions, but the post Kirkup debate must surely include a real focus on how best to ensure midwives work to protect mothers and babies by making appropriate referrals to obstetric colleagues when necessary. We need to be honest about the risks of childbirth and ensure that when mistakes do occur, proper learning takes place.

 –

Whilst we must have a culture that never seeks to blame or punish individuals for genuine mistakes, we must also strive towards a culture that doesn’t tolerate covering up and which holds people to account for recklessness.

 –

The planned changes to midwifery supervision such that the current tier of self regulation that failed so badly at FGH is removed, together with the forthcoming national review of maternity services by NHS England are real opportunities to make lasting changes to improve the safety of maternity care across the system.

 –

I hope this opportunity is embraced by all and that the Kirkup report will one day be looked back on as a real turning point for the safety of midwifery care in the NHS.




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An open letter to Andy Burnham – 12th March 2015  

Dear Andy,


I am writing this open letter to you following the publication of the Morecambe Bay Investigation report on 3rd March. I am grateful for the general apology you have provided on behalf of the last Labour government and for the tone in which you have so far responded.

However, if lasting lessons are going to be learned from what happened at Morecambe Bay, I believe it is vital that some fundamental issues raised both by the Kirkup report and previous high profile reports into serious care quality scandals are now fully and specifically accepted.

I would therefore be grateful for your response to the following points.

1) Rush to FT status. Do you accept that the national pressure and incentives to push as many hospitals as possible to get FT status directly contributed to the tragedies at Morecambe Bay and Mid Staffs?  

 

The Kirkup Inquiry found


‘In early 2009, the Trust was heavily focused on achieving Foundation Trust status, and this played a significant part in what transpired.’ 


‘There was a real desire to maximise the number of Trusts achieving authorisation as FTs.’


‘The Investigation understands that the environment at the time was focused on maximising the number of FTs created, and there was direct and indirect pressure on organisations to progress as rapidly as possible to FT status.’


‘During 2009, achievement of Foundation Trust status remained a prime ambition for the Trust, and we heard consistently that this demanded a high proportion of time and attention from executive directors. ‘ 


‘It is clear from what we heard that the major priorities for the organisation were…the Trust’s ability to achieve financial balance; and achievement of operational targets.  


All of these were key to a successful Foundation Trust application.’


‘From 2008 – 2010, the situation that the Trust still saw achieving Foundation Trust status as its key priority, and it was supported in this by the NW SHA.’

 

This echoes the Francis Inquiry findings: Failure was in part the consequence of allowing a focus on reaching national access targets, achieving financial balance and seeking foundation trust status to be at the cost of delivering acceptable standards of care.’

 

2) Do you apologise for the generalist inspection system? Problems weren’t spotted earlier at Morecambe Bay because the CQC gave the hospital a green ‘all-clear’ rating ahead of the last election in April 2010, which other organisations relied on as evidence all was well.  The report is highly critical of this system of regulation:

 

‘The CQC, a new organisation at that point, adopted a generic approach to utilising its staff, many of whom were from a social care background, and its North West team had little experience of the NHS.  It referred the Trust to the central CQC office for a potential investigation into the maternity incidents, where a podiatrist in central office took the decision not to investigate.’ 


‘What we heard, and saw in documentary evidence, was that there was a gross breakdown of process and communication on the part of the CQC.’


‘On the basis of all the evidence that we have seen and heard, we believe that the failure lay in the underlying lack of organisational competence in the CQC to detect, diagnose and respond to the sort of problems that were evident at the Trust.’ 

 

The Kirkup report also points to important improvements in the  regulatory framework, particularly at the CQC which it says is now: 

 

‘…capable of effectively carrying out its role as principal quality regulator for the first time…central to this has been the introduction of a new inspection regime under a new Chief Inspector of Hospitals.’


‘We believe that external systems are much better placed to detect failed services and to intervene, including particularly the CQC.’


The investigation describes the recent work to place hospitals with high mortality rates into special measures as ‘a clear and commendable initiative to identify problems, not to hide them.’

 

As with Basildon and Tameside, two other hospitals placed into special measures, Morecambe Bay received a clean bill of health from the CQC at the same time as death rates and serious incident numbers indicated there were serious problems.  Do you accept that this inspection system was deeply flawed and that the reforms to the CQC with the new Chief Inspector of Hospitals and expert-led inspections were the right thing to do?

 

3) Do you apologise for the broken performance management system? The performance management system of SHAs and PCTs missed multiple warnings and focused on targets and finances rather than safety and quality, a feature in both Mid Staffs and Morecambe Bay. The Kirkup found that all of the various national and regional bodies tasked with overseeing quality of patient care passed the buck and relied on the findings of other bodies that all was well:  

 

‘Assurance had become circular.  The CQC was taking reassurance from the fact that the PHSO was not investigating; the PHSO was taking assurance that the CQC would investigate, the NW SHA was continuing to give assurances based in part on the CQC position.  Monitor asked for assurance and received the perceived wisdom – that the issues were under control and minimal.’  

 

‘Our conclusion is that these events represent a major failure at almost every level.  There were clinical failures… There were investigatory failures… There were repeated failures to be honest and open with patients, relatives and others… There was significant organisational failure on the part of the CQC… The NW SHA and the PHSO failed to take opportunities that could have brought the problems to light sooner, and the DH was reliant on misleadingly optimistic assessments from the NW SHA.  All of these organisations failed to work together effectively and to communicate effectively, and the result was mutual reassurance concerning the Trust that was based on no substance… We found at least seven significant missed opportunities to intervene over the three years from 2008 (and two previously), across each level  – from the FGH maternity unit upwards.’

 

Francis concluded similarly: The NHS system includes many checks and balances which should have prevented serious systemic failure of this sort. There were and are a plethora of agencies, scrutiny groups, commissioners, regulators and professional bodies, all of whom might have been expected by patients and the public to detect and do something effective to remedy non-compliance with acceptable standards of care.  In short, a system which ought to have picked up and dealt with a deficiency of this scale failed in its primary duty to protect patients and maintain confidence in the healthcare system.  The report has identified numerous warning signs which cumulatively, or in some cases singly, could and should have alerted the system to the problems developing at the Trust.

 

4) Do you apologise for the culture of targets? At both Morecambe Bay and Mid Staffs, the respective inquiries found Boards were obsessed with national targets, which meant clinical quality and patient safety weren’t prioritised.

Kirkup: ‘We heard from a range of executive-level interviewees….that quality and governance had a low profile at the Board, with the predominant focus being on finance and performance targets.’


They described a divisional management structure that was very stretched, with a top-down emphasis on financial balance and achievement of targets.


Francis: ‘This failure was in part the consequence of allowing a focus on reaching national access targets, achieving financial balance and seeking foundation trust status to be at the cost of delivering acceptable standards of care.


Do you accept that this ‘top-down emphasis’ on meeting targets at any cost was a profound policy mistake?


5) Do you apologise for calling Mid Staffs a ‘local failure’? As set out above, the similarities between problems at Mid Staffs, Morecambe Bay, and other hospitals now in special measures such as Basildon and Tameside, are clear. 

In the past, you have argued that Mid Staffs was a ‘local failure’, and accused the current Government of ‘running down the NHS’ and ‘softening it up for privatisation’, when parallels with wider failings have been made. 


However, as demonstrated above, the issues at Morecambe Bay were in many ways identical to those at Mid Staffs, and there were also parallels in many of the hospitals currently in special measures. Will you now accept that Mid Staffs and Morecambe Bay represent more than ‘local failures’ and that there were serious systemic issues as set out above which contributed to both?


Much progress has been made on the patient safety agenda in the last Parliament.  Will  you now commit to continuing the avoidable deaths policy which Jeremy Hunt has recently announced? This will see an annual review of a large national sample of patient case notes – approximately 2000.  The review will be used to establish a national rate of avoidable deaths every year, and on that basis place individual hospitals into bandings according to the number of deaths estimated locally. To place hospitals within the bandings more accurately, their projected share according to the national estimate will be adjusted to take account of each hospital’s known safety metrics.


I understand you plan a mandatory case-note review for all hospital deaths.  However, the Secretary of State said during the Kirkup statement that he has received official advice that this would not be doable in terms of the resources required in clinical time.  As a minimum, will you therefore commit to implementing this plan for a sample case-note review with bandings adjusted for known safety metrics if you become Health Secretary after the election?


Finally, will you commit to retaining the changes to the CQC?  Given the comments the Kirkup report has made about the difference that the new inspection regime has made to patient safety, will you commit to retaining Ofsted style inspections under the direction of the new Chief Inspector of Hospitals, as well as the special measures regime?


I look forward to receiving your full response.


Yours sincerely,


James Titcombe


An open letter to Bernard Jenkin re PHSO  

 

An open letter to Bernard Jenkin re PHSO – 8th March 2015

Dear Bernard,

On Tuesday 3rd March, Dr Kirkup published his report on the failures in maternity care at Furness General Hospital (FGH) between 2004 and 2013. The investigation found 20 instances of significant or major failures of care at the hospital which could have contributed to the deaths of 3 mothers and 16 babies. The report concludes that one mother and 11 babies could have been prevented from dying if they had been given different clinical care. 

My son Joshua was one of those deaths. Joshua died in 2008. It is simply devastating that the report confirms that since 2008 there have been ten deaths at FGH where ‘there were significant or major failures in care’.

The investigation report is careful to state that the ‘validity of decisions taken by the PHSO’ fall outside the terms of reference. However, whilst Dr Kirkup avoids strong direct criticism, the report is highly damning to anyone who knows the full history of PHSO’s involvement.

 In 2009, desperate for help following the coroner’s refusal to open an inquest into Joshua’s death and having become deeply concerned at the dishonestly with which the Trust were responding to what happened, I turned to PHSO. Almost a year later they refused to investigate, citing missing medical records, the fact that CQC were aware of the issues and confidence in the Trust’s action plan as reasons why an investigation by them would be ‘unlikely to result in a worthwhile outcome’. I did everything I could to appeal this decision but these attempts failed. 

 The Morecambe Bay Investigation report talks of a ‘degree of disquiet’ about the PHSO decision not to investigate Joshua’s case and expresses ‘disappointment‘ that having refused to investigate, PHSO then took no steps to ensure the issues were followed up by others in the system.

 The report concludes that  ‘…the PHSO failed to take opportunities that could have brought the problems to light sooner…‘. 

These are serious criticisms given the number of avoidable deaths at FGH that followed. 
After PHSO refused to investigate Joshua’s death, I submitted a complaint about the performance of the North West Strategic Health Authority (NWSHA) and the supervisory investigation undertaken. My complaint was rejected and I was told there was ‘no evidence of maladministration’. I appealed the decision but this also failed.

After losing a child and knowing that things were not done properly in response, I hope you can have some understanding of how devastating the rejection of my complaint felt.

It is only after I started Judicial Review proceedings and sent a ‘letter before claim’ to PHSO that they took legal advice and agreed to review the decision for a second time. This review concluded that the original decision was ‘flawed’ and PHSO subsequently agreed to investigate.  The external review of the decision is damning and can be read here

The PHSO’s eventual investigation was highly critical of the NWSHA and the supervisory system at FGH. These serious criticisms are echoed in the Morecambe Bay Investigation report, yet PHSO refused to investigate despite my going through the formal appeals system. These facts alone should be cause for serious concern. After this experience, I was left with a deep sense of shock at the obstacles that PHSO appeared to construct before they undertook to investigate.

As I am sure you will agree, the Morecambe Bay Investigation report is deeply shocking. The report concludes that a ‘lethal mix’ of factors led to many lives being lost and also describes the apparent actions of midwives at FGH and the Trust itself to cover up what happened. This resulted in lessons not being learned and the same mistakes happening again.

The report found that following serious incidents there had been ‘instances of distortion of the truth.’ This included the‘distortion of the process underlying an inquest‘ and a ‘significant and regrettable attempt to conceal an evident truth, that a cardinal sign of infection in a newborn baby was wrongly ignored’.

These findings relate to the process followed by staff prior to Joshua’s inquest.

At Joshua’s inquest, the Coroner commented that he felt that midwives had ‘collaborated‘ over their evidence and stated that it was simply ‘inconceivable‘ that all of the midwives who gave evidence claimed not to know that a low temperature in a baby was a possible sign of sepsis. 

After the inquest I found evidence that supported the coroners comments. I came across a detailed document containing difficult questions about Joshua’s care and what appeared to be scripted answers. I found out that this document, which mirrored the unlikely evidence provided by staff at the inquest, had been distributed to staff before the inquest took place. I complained about these issues to the Trust, who dismissed my complaint and made various excuses for the sequence of events that happened.

With nowhere else to turn, I asked PHSO to investigate. In February 2014, PHSO published their report. It concluded as follows. 

“I have found no evidence that the Trust, when preparing for the inquest, failed to comply with the law or act in accordance with established good practice. I have seen no evidence that the Trust’s solicitor acted inappropriately, and no evidence that the midwives colluded to present ‘false evidence’ about their knowledge of the implications of a low temperature in a baby. In short, I have found no evidence of maladministration.”

When I received the draft PHSO report by email I was simple devastated. I replied within a few minutes with a deeply angry, very personal and emotional email. 

I repeatedly asked PHSO not to publish this report but they ignored my pleas, stating that it was in the ‘public interest’ to do so. Not only did they publish the report against my wishes, they also published the deeply emotional and personal email, which I wrote at a moment of distress.  I can only assume that they did this to try and discredit me and paint me as someone emotionally unbalanced and unreasonable.

I can not put in to words how distressing and upsetting all this was. Since Joshua’s death I have been meticulous in researching the facts and evidence. I have never sought to misrepresent what happened to Joshua but I have been determined to do my utmost to establish the truth and seek lessons to be learned. It was clear to me that the way in which the Trust prepared prior to Joshua’s inquest was wrong and that staff could not have all been honest in their evidence in relation to Joshua’s low temperature and the link with the risk of infection. 

The PHSO’s report deeply affected me and my family and contributed to what I can only describe as a deep and profound sense of injustice.

This is the context in which I read the Morecambe Bay Investigation report this week.

Dr Kirkup addresses these exact issues in the Executive Summary of the report starting on page 18.

The report states.
“1.22 Third, we believe that this strong desire to protect the group led to instances of distortion of the truth. The strongest evidence of this relates to the failure to recognise the significance of Joshua Titcombe’s low temperature and to act on it. Any clinically qualified member of staff looking after neonates should be aware that a failure to maintain temperature is a cardinal sign of infection in a neonate, and Joshua was under observation for potential infection following his mother’s illness and spontaneous rupture of the membranes. The account subsequently given by every midwife involved, including to the inquest into Joshua’s death, was that none of them knew that hypothermia in a neonate could signify infection or should have resulted in an urgent paediatric assessment. It is on the face of it extraordinary that not a single one knew this basic fact, and many experienced interviewees expressed varying degrees of surprise and disbelief (one local supervising authority (LSA) midwife said to us that a unit in which no midwife knew this would have been unique in her experience22). Moreover, this was not the account initially given to the internal investigation, which was that Joshua’s temperature had not been significantly low, and one midwife said at that stage that she did understand that a low temperature would necessitate a medical assessment.23 Only when Mr and Mrs Titcombe presented a convincing account that Joshua had been significantly hypothermic on two occasions, an account that was accepted by the midwives, did their version of events change to a universal lack of awareness of the significance of neonatal hypothermia. This represents a significant and regrettable attempt to conceal an evident truth, that a cardinal sign of infection in a newborn baby was wrongly ignored.”

“1.23 Fourth, the strong reaction of those who felt themselves under wrongful criticism was allowed to distort some of the processes of investigation that ensued. Again, the clearest evidence related  to Joshua Titcombe, in this case the preparations for the inquest into his death. A meeting took place to prepare the midwives who had been asked to give evidence. This would be entirely in order, and appropriate, given that most would not previously have been involved in such a process, and information on what would happen and what would be expected of them would be helpful both to them and to the process. As part of that meeting, a solicitor working for the Trust’s legal advisors presented a series of ‘difficult questions’ that she felt witnesses were likely to be asked. This would be more controversial, but not in itself improper, provided that there was no general discussion of how to respond, on which both documentary evidence and interviewees are silent. What happened next, however, was clearly wrong: Jeanette Parkinson, the Maternity Risk Manager and Senior Midwife, prepared a single set of what we can only regard as ‘model answers’ to the questions, and circulated them to all of the midwives involved. This distortion of the process underlying an inquest was picked up by the coroner, who commented on the similarity of the accounts that he heard from different witnesses and the concern that this caused him.”

These clear findings of the Morecambe Bay Investigation fully support my concerns and, if these findings are accepted, it can only be the case that the PHSO’s investigation failed to arrive at the truth.

I am fully aware that all large organisations from time to time will make mistakes. When this happens though, there must be a culture in which mistakes or opportunities to learn are embraced.

Last week, Shaun Lintern, a senior journalist at the  Health Service Journal (HSJ) asked PHSO about these issues. In response, PHSO stated that they ‘stood by their investigation’ and claimed that the Morecambe Bay report ‘had not questioned their findings’.

Subsequently, I understand that Bill Kirkup himself intervened and PHSO revised their statement. This time stating “The Morecambe Bay investigation had access to more evidence, including a range of interviews and over 15,000 documents from 22 organisations and therefore it’s not surprising that he reached different conclusions.”

It is hard to comprehend a more irresponsible or arrogant response to circumstances  that have caused so much distress, injustice and hurt. Were it not for the Morecambe Bay investigation, the PHSO’s conclusions would have stood. This is the opposite of what the Ombudsman service should achieve, reinforcing the appalling culture at the trust and making the chances of similar events happening in the future much more likely.

PHSO’s response to these issues shows just how dysfunctional the culture of the organisation has become. No apology, no sense of responsibility or accountability and not even a hint that the organisation intends to learn lessons from a sequence of events that has caused considerable distress.

The PHSO’s response to the Morecambe Bay Investigation report has been nothing short of disgraceful. My family, along with other families whose lives have been devastated by these events now call upon you to ensure that urgent action is taken to change the culture of the PHSO.  It is hard to see how this can be achieved without a change of leadership and direction.

Please do not allow this to go on any longer.

Yours Truly,

 

James Titcombe

 PHSO’s capability questioned after Morecambe Bay report

Exclusive: PHSO’s capability questioned after Morecambe Bay report

The capability of the Parliamentary Health Service Ombudsman to investigate complaints and obtain evidence has been seriously questioned in light of the inquiry into failings at University Hospital of Morecambe Bay Foundation Trust, HSJ can reveal.

Concerns were raised after the Kirkup inquiry’s conclusions contradicted a PHSO investigation last year on the question of whether Morecambe Bay midwives colluded over evidence to an inquest.

The Kirkup inquiry said there was “clear evidence of distortion of the truth” by midwives, describing how they were given a crib sheet of “model answers” before the inquest into the death of Joshua Titcombe, who died as a result of failings at Morecambe Bay in October 2008.

This came a year after ombudsman Dame Julie Mellor said she found no proof that the midwives colluded over evidence. She said she saw no evidence of “professional wrongdoing” by midwives ahead of the inquest taking place.

The PHSO, which is the final arbiter of patient complaints in the NHS, initially issued a statement to HSJ from its managing director Mick Martin in which it stood by its investigation and said the Kirkup inquiry had not questioned its findings.

However, the PHSO this morning decided to revise its statement. HSJ has learned that the change of tack came after the direct intervention from Dr Kirkup.

In the new statement to HSJ, Mr Martin said: “We fully support the report and agree with the findings. Dr Kirkup has provided a comprehensive account of the failings at [the trust].

“The Morecambe Bay investigation had access to more evidence, including a range of interviews and over 15,000 documents from 22 organisations and therefore it’s not surprising that he reached different conclusions. We only reached different conclusions on the preparations made for the inquest.”

Dame Julie Mellor

Dame Julie Mellor said she found no proof that the midwives colluded over evidence

Speaking to HSJ, Dr Kirkup said: “I was surprised when I saw the first statement.”

He added: “The Morecambe Bay investigation findings are based on a careful and thorough review of a great deal of documentary evidence and I am sure our conclusions are robust.”

The inquiry said a meeting with the trust solicitor before the inquest was “entirely in order and appropriate” but added: “What happened next, however, was clearly wrong: Jeanette Parkinson, the maternity risk manager and senior midwife, prepared a single set of what we can only regard as ‘model answers’ to the questions, and circulated them to all of the midwives involved.

“This distortion of the process underlying an inquest was picked up by the coroner, who commented on the similarity of the accounts that he heard from different witnesses and the concern that this caused him.”

The Commons public administration committee is currently investigating the handling of NHS complaints and clinical incidents.

Committee chair Bernard Jenkin said he was concerned at the differences between the Kirkup inquiry and the PHSO investigation, saying: “There is absolutely no dispute that there is a lack of capacity for immediate, objective, independent and confidential investigative capacity into clinical incidents. The capacity simply does not exist and there is confusion about who is responsible for what.

“The PHSO was never set up with clinical incident investigations in mind. It is not a system we are going to recommend that patient safety relies on.”

James Titcombe, father of Joshua and whose campaigning led to the Kirkup inquiry taking place, told HSJ: “If it wasn’t for the Kirkup inquiry the decision of the Ombudsman would have been the final word. It would have vindicated the individuals involved and their behaviour as well as reinforce the poor culture.

“That is the opposite of what the PHSO is supposed to do and increases the chance the same thing will happen again. It is dangerous and only a few weeks ago the Ombudsman said in a statement that they stood by the quality of their investigations.

“The actions of the PHSO are disgraceful. They have revised their statement only after Bill Kirkup intervened. I think Dame Julie should consider her position.”