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

 

2 thoughts on “Safety or Fear?

  1. jesslinworld

    The adversarial process is so inappropriate and distressing. But the NMC should know better about how to treat bereaved parents. Their behaviour is shocking.

    I see all the positives about the new proposals for investigating serious incidents, and that staff shouldn’t be punished for mistakes that a human factors approach can explain, and try to stop happening again.

    However I wonder whether midwives deciding to wilfully exclude medical staff from decision making, contrary to normal guidelines, can be classed as a ‘mistake’. And whether a ‘no blame’ process can deal with this.

    Similarly the psychiatrist caring for Connor Sparrowhawk wilfully ignored Sara’s warnings about seizure activity. This seems to me to be misconduct rather than a mistake. How should that be dealt with?

    Also, in both Joshua’s and Connor’s deaths the people running the trusts ignored reports warning about problems. Where does this fit into the new system?

    Best wishes
    Liz

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  2. Pingback: American Data Network | 6 Stories You Need: IT Rounding, Overriding Medication Safety Technology, Proposed Ban on Powdered Gloves

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