When no one is looking…

On November 5^th 2008, my family suffered a terrible tragedy when our new born baby son died in appalling circumstances following serious failures in his care at Furness General Hospital (FGH)

Whilst Joshua was still alive and fighting for his life at the Freeman Hospital in Newcastle, we recognised that something  had gone very wrong with his care and, prompted by my father’s advice, my wife and I made careful notes about all that we remembered had happened. After Joshua’s death, I typed up these notes and added a list of questions we wanted the trust to answer. In the week after Joshua’s death, my father and I handed this document to the Chief Executive’s office at the FGH (where it was stamped and dated as received).

The document is available here: Joshua Chronology. Please note that you may find this document upsetting – it contains a raw account of what happened to Joshua and photos of him before and after his death.

At this moment in my life, nothing could have prepared me for what was going to follow – the lengths that the trust would go to in order to cover up the truth about what happened and how other organisations that should have been there to step in to protect other mothers and babies were to fail.

The serious dysfunction that led to Joshua’s avoidable death continued at FGH for a number of years. The full scale of the problems at the unit were laid bare by the Kirkup report, published in March 2015. The report concluded that there had been a ‘lethal mix of failures’ at FGH that led to the avoidable death of 1 mother and 11 babies.

One of the organisations that catastrophically failed in its duty was the Nursing and Midwifery Council (NMC). In May 2018, the Professional Standards Agency (PSA) published a detailed review of how the NMC had handled the cases arising from the serious failures in care at FGH, including Joshua’s death. This report is available here. Unsurprisingly, the report led to some serious criticisms of the organisation, I wrote a commentary piece for the Guardian here.

Perhaps the most damning conclusion of the PSA report was paragraph 5.48:

“In our view, transparency involves being open about mistakes, demonstrating learning and can include providing information even where the organisation is not required to do so or where a more restrictive approach is permissible. The NMC’s registrants owe a duty of candour and the approach that the NMC took …. did not convince us that the NMC was applying that duty to itself.”

Today, the NMC have published a new report and statement that throws a little more light on why the PSA came to this conclusion.

A bit of background…

In March 2016, the NMC were finally planning to hold 2 hearings relating to the circumstances surrounding Joshua’s death. Given that this was over 7 years after the events themselves, the NMC had been justifiably criticised for taking so long to act.

These first hearings related to my wife’s care before Joshua was born. We had no strong views either way regarding the care at this point, but in the years since Joshua’s death we learned that the midwifes involved claimed that neither my wife nor myself had had any conversations with them  about feeling poorly in the week before Joshua’s birth. In fact we had discussed this in detail with the staff we spoke to during this time and we were simply reassured that the illness was ‘probably a virus’.  This was all clearly documented in our chronology document. We were deeply distressed that the staff involved were not being honest about this.

When the hearings themselves took place, my wife was asked to give evidence to the panel on 10^th March 2016. During the hearing, a Barrister representing one of the midwives claimed that my wife and I were ‘unreliable’ witnesses, stating that that the first time we mentioned feeling poorly or unwell was at Joshua’s inquest hearing in 2011. The process of being cross examined felt like we were criminals on trial, rather than bereaved parents there to tell the truth about the death of our much loved child.

That evening, ITV news ran a story ‘Parents recollections branded ‘unreliable’ at midwives hearing’ and the following day the local paper ran a similar story in the headlines.

 

We were devastated at these headlines and couldn’t understand why the NMC panel chair had not challenged the comments which clearly weren’t true. It just wasn’t true that the first time we had mentioned feeling poorly prior to Joshua’s birth was at the inquest, so why did the NMC panel not challenge this?

Subsequent to these events, the hearings ended with the NMC taking no action on the grounds that there was apparently no evidence to support the fact that my wife and I had told the midwives about feeling poorly. This felt like a gross injustice given we are both 100% sure such conversations happened (something the Coroner also fully accepted in his summing up of Joshua’s inquest in 2011).

Several phone calls and conversations with the NMC’s former CEO (Jackie Smith) later, and after I sent our chronology document via email to Jackie, it transpires that the NMC panel did not have the chronology document at all – it wasn’t included in the panel of papers given to them.

After the hearings had concluded, I wrote to the Professional Standards Authority (PSA) to express concerns about the way the hearings were handled by the NMC. Following a review, the PSA wrote to the NMC  upholding several issues raised and ruling that the NMC process during the hearings was ‘deficient’.

Bill Kirkup also commented on the situation:

“My major concern is if the panel…didn’t have the relevant evidence in front of it then it’s difficult to know how it can come to a robust and defensible judgment.”

This is all pretty grim stuff, it’s difficult to put into words what it’s like having to go to hearings where you have re-live the circumstances of how your baby son died, having to listen to people who you know are not telling the truth about what really happened, to see the person you love suffering as she has to relive the nightmare and then being  subjected to attempts to discredit your evidence and headlines attacking your credibility in the national media. I can honesty say that the process felt like the worst kind of mental torture imaginable.

But at least the PSA had set the record straight and the NMC would learn from what happened – right? Sadly not. What happened next is one of the most appalling episodes of cover up culture I’ve experienced in the aftermath of Joshua’s death (and there have been many).

To understand how the NMC subsequently behaved, it’s necessary to jump ahead somewhat to  the true reason as to why the chronology document referred to  wasn’t provided to the NMC panel. The truth (and we only know this because of today’s report) was that due to a series of cock-ups, the NMC’s solicitors (Capsticks) did not include the chronology document in the case files that were passed to the NMC. The NMC therefore did not have the chronology document in their possession (although they had been sent in separately on a number of other occasions). Knowing this truth, let’s consider how the NMC responded next.

The NMC’s response

 On 17^th May 2016, the PSA wrote to the NMC setting out the concerns their review had found about the way the cases had been handled. These included the fact that our chronology document was not provided to the panel.

The NMC’s response to the PSA’s letter came on 20^th May 2016. It can only be considered as hyper defensive. The letter stated:

‘…as you know, we do not accept there is a basis for your statement that our decisions were deficient and that we consider it is very misleading.’

At the time, I was shocked at the attitude of the NMC in rejecting the PSA’s comments. The letter went on the give an account to the PSA as to why the chronology document wasn’t provided to the panel. The relevant extract from the letter is copied here.

Not only had the NMC failed to be honest about the fact that the chronology document had been lost, they had now constructed a fabricated set of ‘reasons’ to give the false impression to the PSA  that the document had been considered before the hearing in order to maintain their position of ‘rejecting’ the PSA’s criticisms of their handling of these cases.

In a case where Joshua’s critical medical records had gone missing and there had been so much dishonesty and covering up, the NMC’s description of the contemporaneous  record of Joshua’s short life that my wife and I made at the time as ‘…of no positive evidential value’ was harrowing.

These explanations were repeated in letters to other people, including the Secretary of State for Health.

The Verita Report

The report published by the NMC today has been ongoing for well over year. There have been 4 iterations. The NMC have confirmed the total cost paid to Verita for this work was more than £151,000.  Whilst the report clearly identifies the reasons why the document was missing at the hearings, my strong opinion is that it fails to adequately explain the real reasons why untrue and misleading statements were given to so many people.

Furthermore, the latest version of the report has been significantly watered down to remove the most serious criticisms – comments where the Verita investigators make it clear that in their opinion, there was a likelihood that there had be an ‘…attempt to cover up.’

The NMC had already been publicly criticised for the way they handled the cases, to admit to the PSA that the reasons why an important piece of evidence wasn’t included at the hearings (which the NMC had taken 7 years to progress) was because the document had effectively been lost, would have been highly embarrassing. So rather than being open and honest about what happened, it seems clear to me that the NMC rejected the PSA’s criticism and instead created a false and fabricated account which justified why the document was not available to the panel.  I find the narrative that this happened due to ‘accidental factors’ highly implausible.

Furthermore, the only reason the truth has been established now is because of the  unusual scrutiny of the issue conducted by the PSA in 2018.

The culture at the NMC and its senior team at the time is evidenced by reading the full PSA report. This is an organisation that was willing to spend vast amounts of money redacting personal data requests, who it seems were willing to go to any length to defend themselves from valid criticism. This is behaviour that mirrors the very worst aspects of the cover-up culture that many families still experience from local healthcare organisations

One definition of integrity is ‘doing the right thing, even when no one is watching’; regardless of your views on today’s report, it seems clear that few of the people involved in these events would pass such a test.

Looking forward, I do believe that the NMC now has someone with genuine integrity at the helm. The statement the NMC have published today makes it clear that the organisation is committed to learning from these events.

The NMC must now ensure that the Fitness to Practice process is kinder for both registrants and families that go through it and most importantly,  must role model the same culture, values and standards of behavior it promotes for the people it is responsible for regulating.

The former leadership of the NMC ought to hang their heads in shame that they failed so catastrophically to ensure this was the case.