My son Joshua died a truly horrible and completely preventable death in November 2008 following significant failures in his care at Furness General Hospital (FGH), part of the Morecambe Bay NHS Trust. My life has never been the same since. Despite the 7 years + that have now passed since Joshua’s death not a day goes by when we don’t think about him. Even in the happiest of moments Joshua is in our thoughts. We wonder what he would be like now if he was with us and often wish that he was sharing those happy moments with us.
The past 7 years haven’t been easy but, along with other families affected by what turned out to be one of the worst patient safety scandals in the history of the NHS, we did eventually manage to uncover much of the truth about what went wrong and why. In March 2015, the Morecambe Bay Investigation report Chaired by Dr Bill Kirkup was published. This was a turning point in our journey. Joshua’s death was preventable and contributed to by a ‘lethal mix’ of failures that went on unaddressed for almost a decade. Worse still, Dr Kirkup’s report confirmed that all previous investigations into Joshua’s death (and the majority of the other 20 ‘significant failures’ in care identified by the report) had been woefully inadequate. Critical records had gone missing and there had been deliberate attempts to distort the truth.
The report was clear that what occurred at FGH was not just a matter of system and process issues (although these were plentiful) but that the behaviour and actions of some individuals as viewed by the investigation panel, represented significant lapses from the professional standards expected of them.
Recommendation 19 of Dr Kirkup’s report was for the professional regulators (including the NMC) to carry out their own investigations into the actions of individuals.
Given that 11 babies and a mother died entirely avoidable deaths at FGH (the total extent of harm was much higher) and given that Dr Kirkup’s report confirmed that local investigations into these events were woefully inadequate (or at worse deliberate coverups), it might have reasonably been expected that the NMC might go about this task with some urgency and rigour. What has transpired however, could not be further from such expectations.
Dr Kirkup has described the NMC’s progress as ‘glacially slow’.
In relation to Joshua’s death, the NMC told our family in 2015 that 5 midwives were under investigation and that hearings would be taking place before the end of the year. In September 2015 however, we were told to expect significant delays as the midwives legal representation (provided in many cases by the RCM) had made submissions to try and prevent the hearings going ahead. I argued at the time that given the seriousness of the allegations (how can it get more serious than the preventable death of a child and subsequent covering up) that the NMC ought to at least issue temporary suspension orders until the hearings took place. This didn’t happen.
In March this year, 2 hearings did finally take place. My wife and I attended as witnesses and the experience was truly awful. It felt like we were the ones on trial. The midwives barristers tactics were to try and discredit our evidence and cast my wife and I as ‘unreliable’ witnesses. Since then, Dr Kirkup and the Professional Standards Agency (PSA), the organisation that regulates the NMC, have written to express significant concerns about the NMC’s handling of the cases. The PSA described the process and decision of the NMC (to clear both midwives) as ‘deficient’. (The NMC have not provided me with any information relating to how they are responding to the PSA’s serious criticisms and initially refused to share their correspondence with the PSA with me – an issue we are currently challenging them over.)
In March 2016, I had a meeting with Jackie Daniel, the current Chief Exec at Morecambe Bay. I think that the trust have made some big mistakes since the Kirkup report was published, not least failing to be more proactive in reexamining events that previously hadn’t been investigated adequately to make sure all appropriate action had been taken. However, I do like Jackie and believe that she is doing her best to move the trust in the right direction. During this meeting, Jackie informed me that a midwife currently awaiting an NMC hearing relating to Joshua had been suspended following a recent baby death. No more details were provided. Jackie wanted to tell me in person as she was aware that the case was likely to be reported in the media.
Several thoughts occurred to me. Firstly a deep sense of sorrow for the family involved and the life changing consequences for them. Then I reflected on the upcoming cases and Joshua’s care. The upcoming NMC hearings relate to the time when Joshua was still alive and his care the night before he collapsed. After Joshua’s birth, my wife collapsed with an infection. My wife was treated with antibiotics but we were told Joshua was fine. After an alleged call to a paediatrician (all the paediatricians on duty vigorously deny such a call took place), Joshua was placed on enhanced monitoring. All records of this monitoring (including a bright yellow observation chart) went ‘missing’ after Joshua’s death. My wife was concerned for Joshua throughout the night; in the early hours of the morning calling the bell by her bed because Joshua was ‘grunting’ and breathing quickly. He was just hours away from complete collapse but the midwife who examined him didn’t refer him to a paediatric and instead placed him in a heated cot. A low temperature in a baby is a common indication of infection but the midwife claims the reason Joshua was placed in a heated cot was because the room – which my wife remembers being warm – was ‘cold’ – Joshua’s temperature (of which no documented records exist) – was reported as being ‘normal’.
Joshua’s collapsed from overwhelming sepsis just a few hours later.
Joshua did not die straight away. He spent a further 8 days fighting for his life. Firstly in Manchester and then in Newcastle, strapped to a heart and lung machine for babies. He died at 9 days old when his left lung began to bleed. The bleeding became more and more profuse until there was nothing the staff could do. They turned off the heart and lung machine and Joshua died in diabolical circumstances from internal bleeding.
The midwife involved in Joshua’s care following the call for help was asked to respond to some questions from the NMC in 2009 about her care of Joshua. We later discovered that she emailed her report to a colleague in an email she titled ‘NMC Shit‘ – apparently the title of the email was meant ‘as a joke’.
My family and I can’t understand why it has taken the NMC nearly 8 years to investigate the actions of midwives involved in Joshua’s care. We have repeatedly raised concerns about the lack of progress and why no action has been taken.
Today, the local paper published an article stating that the midwife suspended following the tragic death in March 2016 had now been sacked by the trust:
“Following a disciplinary hearing, the member of staff has been dismissed as the panel felt her conduct fell fundamentally below our acceptable standards.”
I do not know the clinical circumstances involved or whether the midwife’s conduct which the trust say ‘fell fundamentally below… acceptable standards’ was a factor in the tragic outcome (the trusts statement doesn’t make this clear). I do know that Joshua died a terrible and truly preventable death, that my family and I were not told the truth about what happened and that the NMC have failed to take any action despite these circumstances for almost 8 years. I also know that had the NMC implemented the recommendations of the Kirkup review with anything like the expediency that was clearly needed, these hearings would have been completed long before March 2016.
I can not help but feel deeply sad about these circumstances. I am worried that the NMC are continuing to fail to protect mothers and babies and I believe that urgent changes are needed to ensure that professional regulation of midwives and nurses is fit for purpose.