Author Archives: James T

Do we need a review of Midwifery training?

I have been given permission to share this message by the experienced midwife who sent it to me. The midwife wanted to remain anonymous, which I think is a sign of an issue I’ve certainly experienced –  that there is a real fear of raising and debating these issues as when people do, it often generates defensive / hostile responses from some.

Much of this rings true for me, having lost Joshua due a lack of awareness of the midwives looking after him in very basic signs of neonatal sepsis and also being contacted by many families who have experienced loss and harm and listening carefully to their stories.

 Maybe it’s time to review midwifery training to incorporate these lessons? 

“James I am really concerned that part of the problem with low risk perception in midwifery is that the majority of our workforce are no longer dual trained midwives. Those of us left who are also registered nurses will be mostly retired in the next ten years. 

The transition of this workforce to direct entry midwives has coincided with a greater number of women with increased risk factors. This includes women having first pregnancies at a later age. The average age for mothers in 2014 was 30.2 years. There are higher levels of obesity and increased levels of pregnancy induced diabetes. Over a quarter (27.0% of live births in 2014 were born to mothers outside the UK). This greater ethnicity has brought an increase in indigenous physical, mental and social health issues. There are a greater number of women who have moved away from their support network or are unsupported from partners. There is an increase in female smoking, alcohol and substance misuse. There are a number of women having babies who may not have previously survived childhood illnesses or ever contemplated pregnancy (e.g. renal, cardiac disease and some neurological conditions). This explains part of the the reason there has been a reduction in maternal mortality from pregnancy related conditions in the last ten years but three quarters of women who died had a pre-existing medical or mental health condition before they became pregnant. This was mainly pre-existing heart disease, neurological conditions or mental health problems. With the possibility of complications in any mother or baby, midwives need extensive knowledge of co-morbidities and the skills of meticulous monitoring we had to develop as nurses. I for instance cannot listen to a fetal heart without feeling the maternal pulse and assessing its volume, rhythm and character whilst looking at the mother’s skin tone and respirations. Noting her skin temperature, breath smell, temperament, body odour and basically scanning her visually as a six sense before even carrying out any further observations. Hearing a blood pressure with your ears rather than reliance on an electronic sphygmomanometer provides so much more reliable information.

 I would not think of caring for any woman without carrying out meticulous observations of both mother and baby at every point of contact because they are so vulnerable: every step of the way. It is not about medicalising a pregnancy, it is about the fact any woman potentially can develop complications at any stage in the pregnancy, during labour and postnatally. Early recognition, detection and prevention of an adverse outcome is key. I just wonder without an extensive nursing training, that many what I would term as red flags, go undetected.
Of course the same goes for caring for a newborn. That six sense of meticulous observation and assessment. I can never understand how some midwives do not even do observations and teach the mothers at the same time how to recognise abnormality in their babies. As a registered nurse we had to do placements in medical, surgical, paediatrics, maternity, psychiatry, A/E, community, orthopaedics, elderly and social care and ITU…..this does not happen anymore in nursing. There is no longer a paediatric, maternity and psychiatric these are covered by individual qualifications. Another gap in knowledge risk for the workforce.

For those of us left who are dual or triple trained, we had to be a state registered nurse with qualified experience as a registered nurse before doing midwifery. Hence we were a naturally older workforce starting training. We had the same if not more education input but it was within the midwifery unit. We were paid as registered nurses and were already a highly skilled workforce on starting our training which was a further 18 months on the 3 years training we already had. There were no long uni holidays just the same as everyone else. Tutors all on site working alongside you and those who were mentoring you would turn up often unannounced, day and night. Taking midwifery to university put a halt to the apprenticeship style of learning. We did not just have one of two mentors; there was a crowd effect of learning, nurturing and supervision.  

I totally agree midwifery and nursing should be recognised as a degree level course but education should be moved 100% back to the midwifery units (this is where the education team should sit). Separating theoretical education from practical experience can cause break down of communication and disjointed learning. I have not posted this as a general comment as there are very strong opinions to the contrary. My fear is it will worsen now midwives have to pay tuition fees…’s a big financial commitment to study for an additional course and this will further deter nurses from entering the profession. 

This could all be changed by valuing the workforce. Midwifery and nursing students should be paid for working: a band 4 salary. Registered nurses should be encouraged to take up midwifery with the incentive of maintaining a band 5 or 6 salary throughout their training (this should be an additional 18 months). This would solve part of the crisis of lack of recruitment, staff shortages and massive gaps in availability as seen in our current supernumerary student workforce. Bringing back 7.5 hour shifts will reduce the high incidence of sickness, burn out, mistakes because of tiredness and it will also reinstate that valuable shift change over period where so much learning took place. It also allows greater continuity for patients.”

Recent actions of the NMC – a fit for purpose organisation?


Recent actions of the NMC – a fit for purpose organisation?

I had hoped that the days of needing to write blogs like this were over, but reluctantly I’ve decided that writing about this publicly is the right thing to do. This is a long blog, but if you are interested in culture and patient safety in healthcare, please read it.

Since Joshua’s death in 2008, which was finally comprehensively investigated by Morecambe Bay Trust late last year,  the number of organisations I’ve come into contact with has been huge. Many of these organisations failed to respond to Joshua’s death and related events at the hospital where he was born in a reasonable way. The Morecambe Bay Investigation report published in March 2015, sets out serious criticisms of organisations including the Parliamentary and Health Service Ombudsman (PHSO),  Care Quality Commission (CQC), North West Strategic Health Authority (NWSHA) and the Department of Health in some detail. Combined, system wide failures led to serious risks to mothers and babies at Furness General Hospital (FGH) ongoing for several years, resulting in the preventable deaths of 11 babies and 1 mother.

One organisation that didn’t come under much scrutiny in the Kirkup report was the Nursing and Midwifery Council (NMC). One of the reasons for this was because there wasn’t a lot to say about them, as at the time effectively they hadn’t taken any regulatory action what so ever, despite being made aware of the failures relating to Joshua’s death and other babies’ deaths as far back as early 2009.  Following the publication of the Morecambe Bay investigation report, the NMC gave assurances that they would rapidly progress the Morecambe Bay cases they had open and that they would also review the Kirkup report itself to see if any further action was necessary.

Sadly, the NMC’s action since has been described as ‘lamentable’ by Bill Kirkup and heavily criticised by the Professional Standards Authority (PSA) who described the NMC’s handling of the first 2 cases relating to Joshua’s death last year as ‘deficient’.

In a manner that many who have experienced avoidable loss in the NHS will recognise, the NMC’s response to these criticisms wasn’t to say sorry and commit to learn, but rather it was simply to declare that the NMC and the PSA had a ‘difference of opinion’ and to reject the criticisms.

Whilst these issues are disappointing, more recently the actions of the NMC have crossed a line that in my view ought simply not be tolerated.

The Kark Report 

In 2016, a midwife involved in Joshua’s death who  had been under deferred investigative processes by the NMC for several years, was sacked by the Morecambe Bay Trust following the tragic death of another baby. Subsequently, the NMC issued the midwife with an Interim Suspension Order (IO) to ‘protect the public’.

At this point I had a number of serious concerns about this situation. Firstly, the midwife in question was someone who I felt strongly had not only failed in her care of Joshua, but who had also been dishonest about what happened (the latter concern being the issue I would expect a professional regulator to take seriously). This particular midwife was also the author of an email which contained a draft report relating to Joshua’s death,  which she titled ‘NMC Shit’.

It is important to note that very recently the Morecambe Bay trust finally carried out a full investigation into Joshua’s death which concluded the following relating to the actions of this midwife:

“When Hoa called for help at around 2.30am on 28th October 2008, because of concern about Joshua’s breathing, it was ‘highly improbable that there were normal neonatal observations present’ at this time. This is at odds with the statement from the midwife responsible for Joshua’s care at this time who maintained that detailed observations were taken and that all Joshua’s observations were normal.  Whilst there are no records of any of the observations taken of Joshua at the time, (as Joshua’s yellow observation chart has been lost), the Trust acknowledges that this is not a credible version of events based upon the expert view.”

After writing to the NMC to express my concerns, Jackie Smith wrote to me to confirm that she had commissioned an external review. At this time, the NMC publicly said:

“Having now received a new complaint in relation to [the midwife], we feel that it is right that we review the actions that we have taken to date. As an organisation that is committed to continuous improvement we have asked an external adviser to help us undertake this review.”

At this point, I was reassured that the NMC were acting in a reasonably open and transparent way, believing that they had commissioned an independent review to look for opportunities to learn from these circumstances. However, when the review was completed, the NMC publicly commented to say that the review found that “…at no stage during the numerous reviews and investigations which took place was the threshold for applying for and imposing an interim order passed.”

However, when I made a formal request under the Freedom of Information (FoI) Act for the report to be released, the NMC stated that the report was subject to ‘legal privilege’ and they refused to release it. It has since been established that the report was actually carried out by Tom Kark QC (at a cost of more than £12,000 for 1 week’s work).

The concerns I have about this are as follows:

1) When the review was announced, the NMC publicly stated that they had asked an ‘external adviser’ to help undertake the work as they were an ‘organisation that is committed to continuous improvement’. This seems to indicate something quite different from commissioning confidential legal advice from a QC, which could be interpreted as a defensive act, rather than being about transparency and learning.

2) Having completed the review, the NMC have publicly reported on what the apparent positive conclusions of the review were; that at no stage “was the threshold for applying for and imposing an interim order passed”. However, at the same time, the NMC are using legal privilege to withhold the review’s criticisms.  In subsequent phone calls with the NMC, they let slip that actually the Kark report did contain serious criticisms , including an ‘over reliance on the Local Supervisor Investigation (LSA) into Joshua’s death, something I’ve been constantly raising with the NMC for a number of years.

The decision of the NMC to keep this review secret is truly bizarre and has received wide spread criticism.  In my view, these actions demonstrate that there is something wrong with the culture and leadership of the organisation.

The NMC still have one outstanding case open relating to Joshua’s death. It is now fast approaching what should be Joshua’s 9th birthday. These ongoing processes mean that we do have to relive what happened to Joshua – a death that was horrific. The NMC processes last year were perhaps the hardest and most upsetting thing my wife and I have had to do since Joshua’s death. Surely as an organisation, the NMC should be reaching out to families affected by their actions to share any understanding and learning they have and seeking to restore trust through being open and honest and demonstrating learning?

Are these really the actions of an ‘open and transparent’ organisation?  Is it right that registrant fees should be used by the NMC to carry out reviews that are then only partly published, whilst other parts that presumably the NMC’s PR team think don’t flatter the organisation, are kept secret?

More secrecy and defensiveness at a vast cost to registrants

Due to concern about the culture of the NMC and how they have responded to events at Morecambe Bay since being informed of serious issues in 2009, last year I made a request under the Data Protection Act (DPA) for all copies of any of my personal data held by the NMC. After several delays, the NMC eventually provided this information but when it arrived, I was truly shocked at the extent to which the information was redacted. Many documents were completely blank apart from just one or two words. Other documents revealed that the NMC had been monitoring my social media accounts; there were graphs showing the number of my tweets mentioning the NMC and 3 separate emails showing that the NMC had set up a Google Alert for ‘James Titcombe’.

I subsequently asked the NMC under the Freedom of Information (FoI)Act to confirm how much they spent on redacting my personal data, and to my total shock they confirmed that they had paid a top city law firm almost £240,000.

I’ve questioned the NMC on why they needed to use such high level and expensive expertise to respond to a routine request for personal data (all public organisations routinely respond to such requests and doing so certainly shouldn’t necessitate specialist legal advice). The NMC say that this was purely to ensure that the response met their obligations in an ‘open and transparent way’. However, the information released to me has clearly been redacted to a much greater extent than necessary. In fact, it is not possible to make any sense of the vast majority of information provided as in many cases, only a few words per page are all that remains visible.

In these circumstances, I felt that it was important to understand exactly what the NMC instructed the legal firm to do. If the NMC had only instructed them to prepare a fully open and transparent response to my request for personal data, why would releasing their full instructions to their lawyers be a problem?

However, the NMC have refused my FoI request for these instructions, claiming that they are legally privileged.

£240k is the equivalent of over 2,000 annual registration fees of the Midwifes and Nursing who should be able to have confidence and trust in their regulator to act properly and responsibly. As an absolute minimum, shouldn’t the NMC be required to be absolutely open and transparent about the exact scope of work, where the cost is so vast?

Professional Standards Agency (PSA) Investigation

With support from a number of  people, recently the Department of Health agreed to my requests for a fully independent investigation into the NMC’s actions and instructed the PSA to lead this work. It has since been confirmed that this review will include an investigation into the NMC’s secrecy regarding the Kark review, their approach to redacting personal data, the use of £240k of registrants fee’s and the refusal of the NMC to be open and transparent about their instruction to their lawyers relating to this vast sum of money.  Prior to the DoH writing to the PSA to confirm this investigation, the NMC have only ever been secretive and defensive about these issues. However, on the day the news was announced, the NMC put out a press release describing themselves as ‘…an open and transparent organisation, committed to continuous improvement.’

In my view, the opinion pieces from various newspaper reports below are much closer to the mark. What is truly difficult to fathom, is why no immediate action has been taken to restore trust in what is clearly an organisation with dysfunction leadership, badly failing registrants and letting down the very women, babies  and families who they exist to protect.

James Titcombe – April 2017

NMC First


nmc 3


Birth Choice and Information

For some time now I’ve notice a promoted tweet from Which appearing on my timeline linking to a ‘Birth-choice Tool’. The tool is supported by the Royal College of Midwives (RCM), with the Chief Executive of the RCM Cathy Warwick saying that it will “…go a long way towards helping them [pregnant women] make an informed choice and to decide what is the best place for them to give birth.”

The tool has also been endorsed by Julie Cumberlege, the Chair of the National Maternity Review who (see tweet below) also makes a link with Personal Maternity Care  Budgets. (This was a pre decided recommendation of the National Maternity Review).


Providing unbiased information to women and their families so that they can make informed choices about birth-place is clearly important and positive. This is something I can’t see anyone objecting to. But the emphasis here must be on accurate and unbiased information. To this end, I got a bit of a shock when I used the tool and entered various scenarios.

I’ll go through a worked example here.

The first question the tool asks is under the heading ‘Your birth experience’ and asks the question ‘Do you think you will want to use a birthing pool during labour?’.


Of note, the tool cites the benefits of a birthing pool as being coping with pain and being less likely to need an epidural. There is no discussion around published studies around potential risk and benefit.

The next question is ‘Do you think you will want an epidural?’.

My only comment here is that I can imagine for some first time mums they won’t know what to expect or how they will experience pain. Would a better question be ‘do you want to keep the option of having an epidural open’?

On to the next question… ‘How do you see birth’?


I have to say this is the point at which I began to feel really concerned. The tool gives two options.

  1. As a natural event that should take place in a relaxed and private setting.
  2. As a clinical event that needs medical equipment and staff on hand.

It seems to me that the language here is very loaded; ‘natural, relaxed and private’ vs ‘clinical, medical and equipment.’

Is it the case for example that birth in an obstetric led unit can not be ‘relaxed, natural and private’?

The tool then asks the question ‘Are you willing to plan for the possibility of transfer during labour’?


The explanation note does point out that if you plan to give birth at home or in a birth centre you may have to be transferred. It highlights that that such a choice  ‘can reduce your chance of needing medical interventions.’ There is however no mention that for first time mums the transfer rate nationally is 36-40% and there is no discussion about the implications for the safety of mother or baby in the case of a complication arising that necessitates obstetric intervention.

The tool then asks for your age, if it’s your first birth and what your post code is.

In some scenarios, before coming up with the recommended options, the tool will ask an additional question:


‘Do you actively want to avoid the need for medical intervention’?

I have to admit to surprise  when I read this. No matter what choice a woman and her family make about place of birth it surely isn’t possible to ‘avoid the need for medical intervention’. It might be possible to make choices that reduce the chance of experiencing an intervention that may not have been necessary. However, this is complex and in reality, many lives are saved by virtue of mothers giving birth in a setting where risks are carefully monitored and midwives and doctors train and work together to respond to obstetric emergencies promptly. For example, the obstetric unit at Southmead is regarded as one of the safest places anywhere in the world to have a baby.

Nowhere in the tool are the risks associated with childbirth quantified. For example, in 1999 the World Health Organisation (WHO) published research that showed that globally around 15% of all births are complicated by a potentially fatal condition that requires emergency care.

Academic research also that shows that your risk of death is greater on the day you are born, than any other day of your life until you reach the age of 92.

The things that can go wrong in childbirth (for example sepsis, amniotic fluid embolism, haemorrhage, placental abruption, pre-eclampsia) are not things that can be controlled by making a choice about birthplace. They are complications that on rare occasions,  women and babies sadly continue to die from unnecessarily because interventions (sometimes as simple as a single of dose of antibiotics) were denied.

What did the Birthchoice tool recommended in my imagined scenario?

I live approximately 2 miles from Furness General Hospital (FGH). This is a unit that has recently been through a period of significant change and improvement. In many ways, the unit at FGH is now a leading one in terms of safety, quality and experience.

I completed the Birthchoice tool as a young first time mum, 19 years of age with my postcode. I answered all the questions  leaving the slider in the middle (in reality I think the language in the questions is so loaded that I can’t see how it wouldn’t influence the responses). These are the recommendations the Birthchoice tool made:


In my scenario, the tool recommended a freestanding midwifery unit in Penrith, 62.8 miles from my home as a better choice than the unit at Furness General Hospital (FGH) which is just 2 miles away. This recommendation is made for a 19-year-old first time mother.

I always find it interesting to observe the wider context when I come across things like this.

Last week HSJ covered this story stating that there will be a doubling of ‘midwife-led births share by 2020’.

A week earlier, I noticed the following tweets from a midwifery conference attended by senior NHS and RCM midwifery leaders.



The tweet says “Obstetric violence, we have all seen it…” and shows what seems to be a video with a male doctor (presumably an obstetrician) and the words ‘No, no, no. Stay there quietly’. Someone comments that the phrase is worrying and the response is,  ‘it’s very worrying… & exists’.

Last week I also took the time to watch a presentation from Bill Kirkup about events at Morecambe Bay where 16 babies and 3 mothers lost their lives. If you have the time, please watch it also. It is hard for me to reconcile the messages in Dr Kirkup’s report with some of the observations I’ve highlighted in this blog.

I know that there are many fantastic people working hard to ensure safer maternity care is a priority, but is it now time that we saw some national leadership in challenging these issues? If so, would a good place to start be by providing a resource for women and families that really did provide unbiased and accurate information to enable informed choice? Instead of conferences that promote ‘normality’ in childbirth and appear to promote negative messages relating to obstetricians that must be very frightening for women to see, shouldn’t we be holding conferences attended by all professionals involved in delivering maternity care, where we celebrate teamwork, discuss and learn from poor outcomes, listen to all voices and agree actions we can take together to make maternity care safer and better for everyone.

James Titcombe – 8th Jan 2017

A few thanks…..

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

Holding up the mirror

I was disappointed to see some of the news reports following the publication of the CQC inspection report of Bellevue GP practice, where CQC Chief Inspector of Primary Care Steve Field is a partner. 

What was even more disappointing was to see the reaction from some primary care professional (see comments here) which included calls for Field to resign. The full inspection report for the practice is well worth a read

Overall it’s a very good report and describes a service that is well led and indeed delivers outstanding care in some areas. The furore has been caused because the inspection highlighted a few specific areas where CQC felt improvements were needed, particularly around reviewing patients with prescriptions for high risk medication.

For me, far from being a resigning matter, the Bellevue inspection report is something that Field should be in no way embarrassed of. It demonstrates that even well led, caring, effective and responsive organisations need to continuously look for opportunities to improve. The NHS in general would benefit from embracing a culture more accepting of this. Highlighting problems and areas for improvement only becomes a real problem when the response is defensive and changes aren’t made.

The report clearly demonstrates that the inspection process which Field oversees is comprehensive, puts patients first, is independent and most importantly, has the integrity to hold a mirror up to the quality of care being delivered without fear or favour.

Some of us have memories of a very different looking CQC that appeared more interested in it’s own reputation than the safety and experience of the people using the services it is was there to oversee. 

The Bellevue inspection is a sign of how far things have come and something Field and CQC as a whole ought to be proud of.

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


Thoughts about the NMC

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.