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