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.
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.
Guest posts
Guest post: "My son died at Morecambe Bay - opportunities to learn mustn't be missed again"
MumsnetGuestPosts · 26/04/2016 10:47
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.
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?
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. 
I'm so sorry for the loss of your dear son Joshua
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
I am so sorry for the loss of Joshua Thanks for writing this, and for the work you've done.
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So sorry for the loss of Joshua
Excellent post, thank you for all you are doing.
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