Monthly Archives: October 2016

An open letter to Cathy Warwick – 16/10/16

Dear Ms Warwick,

I am writing this open letter to you following the revelations widely reported in the HSJ and other national media last week. 

As you will be aware, in March 2015 the Kirkup report concluded that 11 babies and 1 mother died as a consequence of ‘a lethal mix’ of failures at Furness General Hospital (FGH) from 2004 to 2012. The report states:

“Many of the reactions of maternity unit staff were shaped by denial that there was a problem, their rejection of criticism of them that they felt was unjustified (and which, on occasion, turned to hostility) and a strong group mentality amongst midwives characterised as ‘the musketeers’. We found clear evidence of distortion of the truth in responses to investigation, including particularly the supposed universal lack of knowledge of the significance of hypothermia in a newborn baby, and in this context events such as the disappearance of records, although capable of innocent explanation, concerned us. We also found evidence of inappropriate distortion of the process of preparation for an inquest, with circulation of what we could only describe as ‘model answers’. Central to this was the conflict of roles of one individual who inappropriately combined the functions of senior midwife, maternity risk manager, supervisor of midwives and staff representative.”

You will be aware that the case being discussed here (as detailed later in the Kirkup report) is that of my son Joshua and that the ‘individual’ in question is the person identified in last weeks report as having received an ‘irregular’ payoff in 2012. The report found that the individual ‘appears to have been significantly overpaid’ in a deal described as ‘very irregular in terms of no governance process being followed’. The deal also included an agreement that the trust would not ‘commence an internal investigation into the employee’s performance as maternity risk manager.’

After my son died, the individual in question wrote a supervisory report about his death which was described by the Kirkup report as ‘fundamentally flawed’. 10 babies died following serious failures in care at FGH after my son died. I know that no one goes to work in the NHS to cause harm but to quote from the Kirkup report ‘…where individuals collude in concealing the truth of what has happened…their behaviour is inexcusable.’

You will be aware that following the publication of the Kirkup report, the trust themselves have been working incredibly hard to make improvements; not just to put right the serious deficiencies that led to harm in the past, but to go further with an ambition to be one of the safety maternity units in the country. To the credit of the Chief Executive Jackie Daniel, this commitment to truly learn and be open and transparent about past wrongdoing is being demonstrated by actions as well as words.

The circumstances revealed by the report last week are deeply concerning. An individual with serous questions to answer relating to the tragic events at Morecambe Bay, rather than being subject to a process of investigation to facilitate learning and change, instead was ‘significantly overpaid’ with tax payers money in an exit deal outside any proper governance process.

Despite the shocking legal threat from the Royal College of Midwives attempting to block the release of this report, Jackie Daniel demonstrated last week the trust were no longer willing to bury information and instead chose to be open, honest and transparent.

Rob Webster, former Chief Executive of the NHS Confederation and current Chief Executive of South West Yorkshire NHS FT described Jackie’s actions on twitter as a ‘great example of values based leadership from one of the best CEOs I know.’ Many others have spoken out to say the same.

In this light I was deeply shocked to see the threatening RCM statement which you forwarded to me by email on Friday 14th October which states “The RCM is carefully considering its options to pursue the trust and those involved in the decision to disclose this confidential information’.

John Chrisholm, the Chair of the BMA Medical Ethics Committee said on twitter that these actions are a ‘serious and shameful misjudgement by the RCM’. I would go a step further; the RCM state proudly that they are ‘the UK’s only trade union and professional organisation led by midwives for midwives’ but these actions not only let down a hardworking trust as they seek to make positive changes and demonstrate candour, they let down all of your members who deserve their trade union and professional body to act ethically and with integrity.

I urge you cease these threats and instead use your resources to investigate the role of RCM in helping to negotiate this deal, its implications for patient safety, the hurt and distress caused to families whose loved one’s died as a consequence of the wrongdoing involved, the careless use of tax payers money and the damage such deals cause to the confidence and trust of patients and staff who righty expect the NHS and organisations like the RCM to behave in an ethical way.

If you unable to do this, perhaps it is time that the RCM was led by someone willing to take the organisation in a different direction.

Yours Sincerely,

James Titcombe