The years since Joshua’s death have been a bit ‘up and down’ to say the least. The early years were without doubt the hardest of my life, but in recent years I’ve been able make sense of what happened in a way that has bought some meaning to Joshua’s life and some small sense of closure. The last few months especially I have actually felt a sense of peace and hope that I haven’t had since before Joshua died in November 2008. I remain optimistic about the direction of change and believe that there has never before been a time when so much focus and good work in the area of patient safety has been happening.
There have been some notable exceptions to this general feeling of positivity. The current situation with the Parliamentary and Health Service Ombudsman remains completely unacceptable and has been a source of great frustration.
However, this weekend a letter arrived through my door which really made my heart sink and bought back a sense of sadness that I haven’t felt in a long time.
When the Kirkup report published in March this year, the first ‘national level’ recommendation was as follows.
“In light of the evidence we have heard during the investigation, we consider that the professional regulatory bodies should review the findings of this report in detail with a view to investigating further conduct of the registrants involved in the care of patients during the time period of this investigation.”
There are good reasons for this recommendation. The Kirkup report raised some serious issues relating to the conduct of individuals involved in events at the trust. It is vital that proper hearings are undertaken which allow the evidence to be heard. These events are associated with preventable deaths of mothers and babies and it must be in everyone’s interests to allow a proper, open and fair process to be carried out as soon as possible.
The letter I received was from the Nursing and Midwifery Council (NMC) and provided an update on the progress of the NMC investigations relating to 5 midwives involved in events associated with Joshua’s death.
The letter advised that the legal defence acting for the midwives have ‘…indicated to the NMC that they are likely to make legal applications which, if successful could substantially affect the progress of all of the cases.’ In other words, the legal team acting for the midwives are doing their utmost to further delay these hearings or prevent them from proceeding altogether.
When I read the letter I was reminded of when I first I learned that the legal defence team acting for the midwives involved in Joshua’s death advised them not to cooperate with the Police investigation (the Kirkup report confirms that the majority of staff interviewed by the Police invoked their right to remain silent). I was also reminded that before giving evidence to the Coroner at Joshua’s inquest, ‘model answers’ were distributed to midwives in a process that the trust themselves now accept ‘…went beyond what was proper’. At Joshua’s inquest, the Coroner stated that he believed that the midwives had ‘collaborated’ over key evidence.
During the police investigation, the Royal College of Midwives (RCM) confirmed that they were representing midwives involved in the investigation. I wanted to know whether the RCM were involved in the latest legal attempts to delay or prevent a proper process relating to Joshua’s death from going ahead. In response to my questions relating to this, the RCM have said:
“RCM members have a right to representation and a fair hearing at the NMC. Without such representation in hearings, which could result, potentially in their being bared from their profession and career, there is the potential for injustice. The RCM, as a professional body and trade union, does provide such support to its members.”
I’ve been reflecting on what ethical responsibility organisations that commission legal services should also have towards families affected by avoidable tragedies and the injustice caused to such people by constant attempts to obfuscate processes designed to establish truthful answers and ensure appropriate accountability?
When the PHSO report in to the Local Supervisory System regarding Joshua’s death was first published, I recall the RCM saying in a TV interview that ‘…we mustn’t throw the baby out with the bath water’. The RCM response has been defensive and quite painful to watch unfold. In reality, it should never have taken complaints from bereaved parents to force such changes. Shouldn’t an effective professional body have recognised the need for change and acted much sooner?
My other great frustration is with the RCM’s ‘normal birth’ campaign. I have long thought that such a blunt tool was an inappropriate way of trying to address a complex set of issues. There is no doubt in my mind that the agenda set at national level by the RCM’s campaign heavily contributed towards the thinking and ethos of the midwives at Morecambe Bay. I remain concerned that although the name of the campaign has now changed, the RCM still champion a top down and blunt national campaign which promotes ‘normality’. In my view, this risks encouraging the same sort of approach that led to the tragedies at Morecambe Bay
In this context, the response from the RCM to the Kirkup report has also been frustrating at times. For example, this comment from Lesley Page.
“The press has picked up on the report’s emphasis on “the ethos of normal or natural birth ‘at all costs’ at the unit which resulted in inappropriate and unsafe care” (Kirkup, 2015, p. 13, 1.4.) I searched carefully to find out what was the basis of this emphasis but couldn’t find much.”
Myself and other families who lost loved ones as a consequence of what happened at Morecambe Bay find this comment unacceptable. Perhaps the RCM will take up the offers below and meet some of the families affected by what happened so they can better understand the clinical situations?
All this leads me to the view that the RCM themselves are a major problem. It seems to me that it is the trade union / medical defence role of the RCM, not their professional body role that has shaped the RCM’s response to events at Morecambe Bay.
In my view, 2 clear questions come to mind.
1) Is it time that the professional body role of the RCM was separated from the trade union / medical defence role?
2) Is it time that we had an ethical code of conduct for organisations that commission legal services relating to the NHS, where the impact on families who have suffered avoidable loss and overall public interest has to be properly considered?