Talk

Advanced search
MumsnetGuestPosts (MNHQ) Tue 26-Apr-16 10:47:49

Guest post: "My son died at Morecambe Bay - opportunities to learn mustn't be missed again"

James Titcombe says the hardest part of coming to terms with his son's death was how the NHS responded - but now, the culture of blame is changing

James Titcombe

Posted on: Tue 26-Apr-16 10:47:49

(16 comments )

Lead photo

"When an avoidable death does occur, there can be no excuse for not making sure lessons are learned to safeguard others."

In 2008 I lost my baby son Joshua as a consequence of failures at Morecambe Bay.

When he was born, my wife and I raised many concerns about Joshua. His temperature was persistently low, his breathing was too quick. The midwives looking after him reassured us that he was fine and he wasn't referred to a doctor until he collapsed from overwhelming sepsis at 24 hours of age.

After eight days of battling for his life, Joshua passed away and the hardest part of coming to terms with his loss was the way the NHS responded.

The coroner refused to open an inquest on the grounds that Joshua had died from 'natural causes' and we were advised to make a 'complaint' to the trust in order to have our concerns addressed.

However, a few weeks after Joshua's death, the trust advised us that critical medical records had gone missing. The trust carried out an investigation and although they accepted that they failed Joshua, we were left with many unanswered questions as to what happened and why.

After talking to other families, it soon became clear that Joshua's death was not just a 'one off' in that unit.

Despite many attempts to try and ensure the system responded to what happened to Joshua - it didn't. More lives were lost as a result.

Had the trust responded to the first tragedy in the maternity unit with openness within a true learning culture, I am sure that Joshua would now be happy seven-year-old boy, and the course of my life would be completely different.


When Joshua died, I was working as a project manager at Sellafield in Cumbria, the largest nuclear site in the UK. Safety was the highest priority. Even the simplest of jobs in a radioactive area would take meticulous risk assessments. But safety was never viewed as a 'tick box' exercise. Mistakes and failure were regarded as vital opportunities to learn and improve.

It is in this context that I met the system response to Joshua's death with a sense of shock and dismay. The trust - and the wider NHS system - seemed more interested in keeping 'bad news quiet'.

Facing up to these issues is a real challenge and, over the past few years, the direction of travel has shifted markedly.

Healthcare is complex and we must accept that from time to time, those working within it will make mistakes; to err is human. Systems and processes should be designed and in place to minimise the chance of human error leading to harm, but when something as tragic as an avoidable death does occur, there can be no excuse for not making sure lessons are learned to safeguard others.

To break the cycle of failing to learn, healthcare professionals must feel safe, confident and supported. Fear and blame are the enemies of a true learning culture.

Over the last year, I've been privileged to provide advice and guidance on the setting up of the new Healthcare Safety Investigations Branch, set to be launched later this year. This represents an exciting opportunity to support these changes here in England.

Had the trust responded to the first tragedy in the maternity unit with openness within a true learning culture, I am sure that Joshua would now be happy seven-year-old boy, and that the course of my life and many other families would be completely different.

Time and time again, we hear the promise that 'lessons will be learned' following reports about systemic failures and individual stories of avoidable harm and loss in the NHS. Yet, far too often, the same mistakes are repeated and meaningful learning and lasting change simply doesn't happen.

If we are going to transform this, it's clear that we need to do something different. Events at Mid Staffs and Morecambe Bay serve to highlight the devastating consequences of a culture that fails to learn.

So I welcome the introduction of an independent Healthcare Safety Investigation Branch and legal protection for anyone giving information following a hospital mistake. It is also important that expert medical examiners will soon independently review the cause of all deaths and decide if any need to be investigated. Repeated mistakes can be identified quickly and action taken.

Such fundamental changes are important steps forward but over the next few years, the challenge for the NHS, and I am sure other healthcare services across the world, must be to ensure that opportunities to learn are never missed again. I hope the Global Patient Safety Summit held in London in March will be the start of a process of sharing experience and expertise across the globe.

By James Titcombe

Twitter: @JamesTitcombe

redexpat Tue 26-Apr-16 12:47:43

flowers I'm so sorry for your loss and the reaction of the Trust.

GoodStuffAnnie Tue 26-Apr-16 13:02:33

I am so sorry for the loss of your perfect son.

This new branch sounds like a great idea. I just read the link. So positive. It has to be about learning. People have to be undefensive.

Another area that is similar to this is close to my own heart. All health professionals have to start really listening to mums and dads. Much of modern society is evidence based and quantitive. We have to remember instincts. I know of several stories where children have died due to parents being ignored or not listened to or survived due to parents Being taken seriously. Mums and dads matter.

Lots of love xxx

KimmySchmidtsSmile Tue 26-Apr-16 13:15:57

daffodil There are no words for the injustice you and your wife have suffered, and the other families pre and post Joshua's birth. My heart goes out to you. What you have done though in persisting on undercovering the truth, in spite of all the odds against you, is nothing short of heroic. Thank you for your determination and courage.

KittyandTeal Tue 26-Apr-16 14:12:45

I cannot imagine the pain and suffering of loosing a child and then having to battle against a healthcare trust intent on covering up mistakes.

💐

Lalalalalalaloooooo Tue 26-Apr-16 18:08:33

flowers sorry for your loss. I can't imagine what you've been through. And thank you for your determination to expose this and improve the system. Thanks to you and people like you the services are becoming safer for the rest of us. What will the investigation branch do? Will it only investigate deaths or will it be able to investigate other incidents? Will the NHS still handle its own complaints process?

Duckdeamon Tue 26-Apr-16 18:10:42

I am very sorry for the loss of Joshua.

It's admirable that you have used your professional knowledge and skills to help make change to improve things for other people. Thank you for this and your guest post. brewflowers

I'm so sorry for the loss of your dear son Joshua flowers

Having worked in the NHS as a student nurse I think there is room for improvement in care, especially in terms of training, looking at the systems and practices, and learning from mistakes, as you so wisely highlight.

Thank you for sharing your experience, both personal and professional, to make things better for others flowers

Lupin32 Tue 26-Apr-16 21:16:11

I am so sorry for the loss of Joshua flowers Thanks for writing this, and for the work you've done.

mammmamia Tue 26-Apr-16 23:55:37

I am sorry for your loss. You are amazing to have used your experience in this way. Thank you.

beesarethebest Wed 27-Apr-16 06:59:04

I'm so sorry to read about your loss. My son was also born in 2008. I agree with you entirely about the NHS and how it should and can learn from errors because to err is human. Our experiences at Great Ormond St have taught us that there is a fantastic group of doctors (junior and senior) who are willing to listen to parents and willing to move mountains for us. This unfortunately was not the case at other hospitals and even at the GP clinic. My son is now in remission thankfully but this is entirely thanks to GOSH and our persistence as parents. The number of times we were fobbed off by doctors both in the GP and in other hospitals saying he was 'behaving like a 4 year old', 'just having a viral' was just astounding.

Good luck for the future.

beesarethebest Wed 27-Apr-16 06:59:08

I'm so sorry to read about your loss. My son was also born in 2008. I agree with you entirely about the NHS and how it should and can learn from errors because to err is human. Our experiences at Great Ormond St have taught us that there is a fantastic group of doctors (junior and senior) who are willing to listen to parents and willing to move mountains for us. This unfortunately was not the case at other hospitals and even at the GP clinic. My son is now in remission thankfully but this is entirely thanks to GOSH and our persistence as parents. The number of times we were fobbed off by doctors both in the GP and in other hospitals saying he was 'behaving like a 4 year old', 'just having a viral' was just astounding.

Good luck for the future.

JamesTitcombe Wed 27-Apr-16 09:43:27

Thanks so much for all the kind comments here. Since Joshua's death, I do think there have been some really positive changes but there is still along way to go. The NHS needs to get much better at investigating and learning when things go wrong and more support is needed when families suffer avoidable loss. I think the new investigations body will make a big difference.

If anyone is interested in reading more about what happened to Joshua - I've written a book 'Joshua's Story' which is available on Amazon.

Wherediditland Wed 27-Apr-16 15:16:42

I'm so sorry for the loss of your son.

That you have continued to try and work with those in the NHS to prevent another family suffering as you have is admirable.

I work in the NHS and it easy for us to become defensive and hypersensitive to any criticism because we get so much of it.
It is truth that we must be open and learn from mistakes to forge systems and a culture that allows safety to be promoted.
Above all we should pause and listen and always wonder are we seeing/hearing clues that we cannot ignore.

I will learn today from your post and take that with me.

PirateSmile Wed 27-Apr-16 18:07:48

I am extremely sorry for the loss of your precious son.
It is extraordinary that you are using your experience to improve the lives of all those who may be affected by such tragedy in the future. You have my utter admiration.

WhenSheWasBadSheWasHorrid Wed 27-Apr-16 23:47:30

So sorry for the loss of Joshua flowers

Excellent post, thank you for all you are doing.

BonerSibary Tue 03-May-16 21:26:41

The NHS and also various leading figures in midwifery treated you disgustingly James. I encourage those reading to look up how attempts were made to silence you. Well done and thank you for all the work you're doing to try and ensure this doesn't happen again. It's a fitting memorial for your boy.

Join the discussion

Join the discussion

Registering is free, easy, and means you can join in the discussion, get discounts, win prizes and lots more.

Register now