Monthly Archives: March 2016

Safety or Fear?

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

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

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

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

JOSHUA-TITCOMBE-SO_3446288b

Joshua – 27th October 2008

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

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

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

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

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

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

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

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

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

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

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

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

Hunt quoted Dr.Lucian Leape

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

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

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

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

The article read

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

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

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

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

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

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

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

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

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

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

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

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

 

James Titcombe – March 16th 2016

 

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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