Jane Feinmann: Joshua’s story and its impact on patient safety

jane_feinmannLike most people who complain about unsafe healthcare, James Titcombe’s six year battle to hold Morecambe Bay Trust to account for the death of his nine day old son in 2008 was motivated “by the desire to prevent similar tragedies happening to others.” And like many, as he explains in his new book, Joshua’s Story, “the saddest memory is not his (Joshua’s) death but the events that took place afterwards”: a cover-up at local level that led to “missed opportunities to intervene at almost every level of the NHS” and almost certainly, according to Titcombe involved “an element of deliberate suppression.”

Yet Joshua’s story is also unique—as became clear at the launch of the book last week at the health charity the Kings Fund. For a start, the author is not just a bereaved father and patient safety campaigner but also, since September 2013, the National Safety Officer of the newly empowered Care Quality Commission. Further, Health Secretary Jeremy Hunt stood alongside James Titcombe—clearly passionately determined to show that the NHS that covered up the causes of the baby’s death is on the way out.

Mr Hunt took time out from the Commons debate on Syria to pay tribute to James Titcombe’s “incredible bravery at huge personal cost.” He also spoke of his determination that “the NHS will blaze a trail in safe healthcare globally”—with British doctors taking a lead “in routinely learning from their mistakes in the same way as the aviation industry has chosen to do.” There’s already been progress, Mr Hunt insisted: notably a 25 per cent increase in the number of patient safety harm episodes reported annually. But with “200 avoidable deaths every single week and wrong site surgery occurring twice a week in the NHS, there’s still far too much harm,” he told the meeting.

The launch chair, Phil Hammond said the book was an investigation of the “psychology of cover-ups in the NHS.” And certainly Joshua’s Story illustrates vividly the sometimes preposterous arguments that health managers are able to employ to avoid learning from mistakes.

Just 20 days after the baby’s death from unrecognised sepsis, the hospital’s “customer services manager” informed the parents—without explanation—that Joshua’s observation records had “gone missing.” A year later, the Parliamentary and Health Service Ombudsman—”the only organisation in the entire hierarchy of the NHS with the power to properly investigate the complaint”—turned down Titcombe’s heart-rending pleas to investigate the how and why of the missing records. The reason, a modern day Catch 22 classic: “Joshua’s medical records are missing for the crucial first 24 hours of his life,” the then Ombudsman, Ann Abraham explained in a letter in November 2009. She went on: “It is therefore highly unlikely that we would be able to reach a firm finding on what took place and why.”

The consequences of this decision became clear five and a half years later in March 2015, when the Kirkup report revealed that between January 2004 and January 2013, there had been 20 instances of “significant or major failures of care.” These were associated with the deaths of three mothers and 16 babies—four times the number of failures of care at another of the Trust’s maternity units which had a higher number of births per year. Ten of these deaths occurred in the years after the PHSO turned down James Titcombe’s request for an enquiry.

Joshua’s Story is not a medical scandal as such. But anyone with an interest in patient safety in today’s NHS will find Joshua’s Story both moving and inspirational. Read it and you may even agree with Mr Hunt who describes it as “a wake up call about how our healthcare system has to change so we learn from tragedies rather than sweep them under the carpet.”

Jane Feinmann is a freelance medical journalist  with a particular interest in patient safety based in London. She belongs to Imperial College Health Partners’ Patient Safety Champion Network.

Competing interests: The author has no competing interests to declare.