patientsafetyfirst

A few thanks…..

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2016 has been a very busy year personally and for patient safety in England. I wanted to write a quick blog to thank a few people who have made a difference.

In February, a report commissioned by NHS England relating to the tragic loss of baby Kate Stanton-Davies in 2009 was published. The report only came about because of the hard work and determination of Kate’s parents Richard and Rhiannon. The report was shocking for many reasons, including the fact findings  were very different to the initial supervisory investigation carried out following baby Kate’s death and identified failures that had previously not been acknowledged.The report also made the recommendation for there to be a national audit of the quality of similar supervisory investigations following serious incidents/avoidable deaths in maternity services. A big thank you to Richard and Rhiannon for all they have done to push for the truth about Kate’s loss and for there to be national learning. 2017 will be an important year for midwifery and a new model of supervision is being developed, it’s vital that Kate’s story and the results of the national audit feed into the new model.

It’s been approaching 2 years since the Morecambe Bay Investigation report was published. If I’m being frank, I have a growing concern that some of the key messages of the Morecambe Bay report, especially amongst some elements within Midwifery, risk being lost and overlooked. However, since publication, the Chair of the Morecambe Bay Investigation Dr Bill Kirkup has consistently and superbly kept a focus on the issues. This has included articles and talks at high profile events about what happened at Morecambe Bay and what the keys message are.

If you only have 30 mins to spare to learn about Morecambe Bay, please watch this talk from Bill, it’s so important that these messages aren’t lost or forgotten.

I’d like to repeat my thanks to the whole Morecambe Bay Investigation panel, but especially to Bill Kirkup for working so hard to spread the learning from his report.

Another area of significant progress in 2016 has been the establishment of a new Healthcare Safety Investigations Branch (HSIB), which is set to go operational in April next year.  This new body has come about as a consequence of sustained effort from people like Martin Bromiley and the Clinical Human Factors Group (CHFG) and others. A breakthrough moment was when Carl Macrea and Charles Vincent published their paper ‘Learning from failure: the need for independent safety investigation in healthcare’ towards the end of 2014. The paper was read by Bernard Jenkin MP, the Chair of Public Administration Select Committee (PASC) who also became a passionate champion for the creation of the new body and set up a PASC inquiry which made recommendations that the government supported.

Another person who in my mind has made a huge difference in 2016, is the Patient Safety Correspondent at the HSJ, Shaun Lintern. I highly recommend watching this recent talk by Shaun which highlights the mountain that we still have to climb in improving safety and culture in the NHS. I also recommended this piece and hope 2017 will be a year we make real progress in changing this.

Earlier this month, the Care Quality Commission (CQC) published a comprehensive report into the quality of investigations and learning following the deaths of patients in the NHS. This is a report that everyone working in healthcare should read. It wouldn’t have come about without the considerable efforts of the family of Conner Sparrowhawk, whose preventable death whilst in the care of Southern Health (and the appalling way the trust responded), triggered the Mazars report and subsequently the CQC review.

Before 2017 arrives, I’d like to say a big thank you to the Chief Executive of Morecambe Bay, Jackie Daniel and all the staff at the Trust. My relationship with Morecambe Bay has been a turbulent one since Joshua’s death as until recently, I have felt that there has been a lack of ownership for what happen and that questions about what happened to Joshua and why remained unanswered.

I must say that during the past year, Jackie and the team at Morecambe Bay could not have worked any closer with me to resolve this. Jackie has shown huge understanding, thoughtfulness and compassion.

As part of the work the Trust did with me, it was discovered that a senior midwife central to events at the trust and involved in a flawed investigation into Joshua’s death, had received an ‘irregular payoff’ in a deal that avoided an internal trust investigation. Before these facts were made public, Jackie was issued with a legal injunction by the Royal College of Midwives (RCM) to try and ensure the circumstances of what happened were kept secret. I think it shows huge moral courage that Jackie ignored the legal threat and did the morally right thing by releasing the report regardless.

On 4th November 2016, a day before the 8th anniversary of Joshua’s death, the Trust published a summary report of their recent investigation on their website.

The report is honest, thorough and accurate. I now feel that the Morecambe Bay trust genuinely does ‘own’ what happened to Joshua and I  believe that they will ensure the lessons from his death and other tragic events, are never forgotten.

In 2008, it is now abundantly clear that Morecambe Bay was a trust that had much to learn from the wider NHS. As we approach 2017, I honestly believe that it is the wider NHS that has much to learn from Morecambe Bay. Once again, huge thanks to Jackie and the team at Morecambe Bay for all your hard work.

It’s not possible to mention all the other people who continue to make a difference, but thanks to everyone who works to make healthcare safer and wishing you all a very Happy New Year and all the best for 2017.

James Titcombe – 31.12.16

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