A few weeks ago, Joshua Titcombe should have celebrated his seventh birthday. Instead, Joshua died at just nine days old, as a result of some very basic medical errors by midwives at Furness General Hospital.
Joshua’s Story: Uncovering the Morecambe Bay NHS Scandal is James Titcombe’s account of Joshua’s life and death, his long battle to find the truth about why his son died and his determination to make sure that the same mistakes couldn’t happen again.
James’s wife Hoa gave birth to Joshua at 37 weeks. Hoa had a sore throat and headache at the time, but midwives declined the opportunity to give her antibiotics as a precautionary measure. When both Hoa and Joshua became ill shortly after birth, Hoa was administered antibiotics, but Joshua was not – despite James’s repeated requests.
After that, the tragedy unfolds with a horrifying inevitability: Titcombe describes how his son became very ill and had to be taken to hospital in Newcastle to receive a treatment called Extra Corporeal Membrane Oxygenation. The treatment was unsuccessful, and Joshua died.
Joshua’s life could almost certainly have been saved if he had been given antibiotics in time. The key indication was a drop in his body temperature: James and Hua didn’t know this then, but in babies, a low temperature is a sign of infection. The response of midwives, however, was to keep Joshua warm by putting him in a heated cot with an overhead heater.
It took six years from Joshua’s death to the publication of the Kirkup report, a damning investigation into the maternity unit at Furness General.
James Titcombe’s account of those six years is mesmerising. Determined to find out why his son hadn’t been properly treated, he took his complaint to every authority that might be able to help – the trust chief executive, the Care Quality Commission (CQC), the Nursing and Midwifery Council (NMC), the parliamentary and health service ombudsman, his MP and the police. He also wrote to both the Newcastle coroner and his local coroner asking for an inquest.
At every turn, he was blocked. A report by the Local Supervising Authority (which has statutory responsibility for governing midwives) was a whitewash. Both the coroner and the ombudsman initially refused to investigate. The trust chief executive admitted that errors had been made but said that lessons had been learnt and refused to investigate further.
What is extraordinary is that James Titcombe kept going. He wrote endless letters and emails and had numerous meetings with people from the relevant organisations. While the authorities appeared determined to shut him up, he was equally determined not to be fobbed off. The scandalous fact that a key piece of evidence (an observation chart recording Joshua’s low temperature) had gone missing was given as a reason not to investigate, on the basis that, without this evidence, it would be impossible to determine what exactly had happened. Yet, as Titcombe points out, the suspicious fact that a crucial document is missing is surely a reason why you should investigate.
Eventually, Titcombe’s sheer dogged determination led both to an inquest and an investigation by the ombudsman, and those in turn led to the Kirkup report. But why was it so difficult? It becomes clear early on in the book that crucial facts were covered up (for example, Titcombe only later became aware that other babies had died at the unit, both before and after Joshua, as a result of medical negligence). Even at the inquest, three midwives categorically denied that they knew that a low temperature could be a sign of infection – presumably on the basis that it is better, as a health professional, to appear ignorant of basic medical facts, than it is to admit that one is aware of the facts but has decided not to act on them.
Failure to work together
Even now, it’s not clear to me why the midwives refused to give Joshua antibiotics. The Kirkup report talks of an “extremely poor” working relationship between midwives and doctors at the unit, and a determination by midwives to push normal birth at all costs. But Joshua didn’t die as a result of an over-zealous adherence to normal birth (though other babies did): he died because of a refusal to administer antibiotics. Astonishing as it may appear, this seems to have been down to a reluctance on the part of midwives to consult paediatricians. (At the inquest, midwives claimed that they bleeped a paediatrician for advice about Joshua, and the paediatrician had advised them simply to keep an eye on him; all the paediatricians on duty at the time denied having received such a call.)
Blaming the messenger
One of the many dispiriting aspects of the book is the clear unwillingness of the hospital to investigate safety incidents properly. Titcombe rightly points out that in other industries, there is a culture of openness about safety errors. The aviation industry, for example, has vastly improved its safety record by requiring staff to report their own mistakes, with no blame attached: if there is a pattern of people admitting similar mistakes, it’s possible to change procedures or designs so that those mistakes aren’t made in future. At Furness General, the immediate response to mistakes was to cover them up. There was clearly also a strong culture of blaming the messenger: it’s obvious that staff and, sadly, even patients were angry at Titcombe for his persistence in trying to find the truth of what happened. At one point Titcombe sees an email from the head of midwifery in response to “good news” mentioned in another email. “Has Mr T moved to Thailand?” the midwife’s email speculates hopefully – a confused reference to the fact that Hua is Vietnamese.
By the end of the book, I could only marvel both at James Titcombe’s dedication to finding out the truth and at the authorities’ dedication (with the exceptions of a few principled individuals) to stopping him. But I’m glad that he gives over the appendix to another couple, the parents of Alex Davey-Brady, to give their account of how their baby son died as the result of yet another medical error at Furness General. Because their first baby had been large, they were concerned that their second baby would be too, and they wanted an early delivery. This didn’t happen: an induction finally took place at 39 weeks, followed by a difficult labour. Alex was stillborn, weighing nearly 12lb, and with the umbilical cord wrapped around his neck. Alex’s parents are less polished writers than Titcombe, but the account is all the more moving for that.
They speak of their frustration at others’ unwillingness to take their story seriously, and say: “I would like to think that as a parent, if we had received excellent care with Alex and he would be here today going to school and causing mayhem like most little boys, I would be open minded enough to read this story told by someone else and not turn a blind eye and say the truth has to come out so that the future can move on in a more positive and more importantly more trusting path.”
Amen to that.