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SPEAK OUT SAFELY WEEK

James Titcombe: 'The NHS I encountered treated my son's death as an inconvenient issue'

The only way to guarantee that patient safety is genuinely put first is by ensuring concerns are raised and not kept quiet, says James Titcombe

My life was forever changed in November 2008 when I lost my baby son due to failures in his care at the hospital where he was born. Joshua lived for nine days. On his first day, Joshua endured the worst standard of care possible. When he became seriously ill the next day, we witnessed the NHS at its very best.  

Joshua was transferred to Manchester St Mary’s where a consultant was called from home in the early hours of the morning to help stabilise him. He was later flown by helicopter to the Freeman Hospital in Newcastle where he received intensive care from a dedicated team of consultants and neonatal specialists. Despite their very best efforts, Joshua couldn’t pull through. The damage done from an infection that could easily have been treated at birth was too great. At just nine days old, our son, born perfect in every way, died from an infection that could have been cured with a single dose of antibiotics.

No words can describe the pain of losing Josh, but there were too many unanswered questions simply to grieve and move on. I knew something had gone badly wrong and needed to understand why.

I did not realise just how hard getting those answers would be. The NHS I encountered treated my son’s death as an inconvenient “issue” that needed to be dealt with.

Critical medical records went missing, the trust did not conduct an adequate investigation and other authorities I turned to for help failed to listen. We encountered a system that was closed, defensive, legalistic and reluctant to learn. 

In recent years, report after report has confirmed that our experience is far from unique.

While many parts of the NHS work well and deliver high standards of care, too often the NHS has failed to get the very basics right.

The Francis report into the terrible failures at Mid Staffs found “an institutional culture that put the business of the system ahead of … the protection of patients”.

The recent Grant Thornton report into the actions of the Care Quality Commission at Morecambe Bay exposed just how flawed the regulatory system has been.

In the words of Don Berwick, “the only conceivable worthy honour to those harmed is to make changes that will save other people and other places from similar harm”. To do this, Professor Berwick says “the NHS must place the quality of patient care, especially patient safety, above all other aims”.

Professor Berwick has laid down a huge challenge to all those who work in the NHS and its regulation. The aspiration to ensure patient safety is really put before all other aims can only be met if the culture within the entire system is right. 

My own experience has shown me how good the NHS can be. Joshua’s care in Newcastle was second to none.

At its best, the NHS is an institution of which we can all be proud.

But, when problems exist, the only way to guarantee that patient safety is genuinely put first is by ensuring concerns are raised and not kept quiet.

It is vital that all those in leadership positions in the NHS act to encourage all staff to report known concerns openly and to be explicit in ensuring staff are properly supported and protected when they do. 

The Nursing Times Speak out Safety campaign is a pledge to do just this and I encourage all NHS trusts to consider signing up.

James Titcombe is a patient safety campaigner

Readers' comments (3)

  • michael stone

    'We encountered a system that was closed, defensive, legalistic and reluctant to learn.'

    That is a very common experience: will it change - who knows ?!

    How can it be changed ? Presumably by not blaming people for 'no genuine culpabilty' 'mistakes' and coming down heavy on 'clear incompetence and 'systemic bad behaviour'', but again, I'll believe it when I see it.

    The NT campaign is a step in the right direction.

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  • tinkerbell

    James my heartfelt sympathy to your and your family.

    'In the words of Don Berwick, “the only conceivable worthy honour to those harmed is to make changes that will save other people and other places from similar harm”. To do this, Professor Berwick says “the NHS must place the quality of patient care, especially patient safety, above all other aims'. I totally agree.

    Openess & honesty has to be the way forward. Most reasonable people can deal with the truth. When they have to struggle to get to the truth and jump through hoops and are told anything less it creates more suspicion so much so that in the end even if some part is true it is doubted. Like Peter & the wolf.

    Can we move away from this arse covering culture? Who knows, but we have to try.

    Tragedy will continue to happen, we are all only human, hopefully genuine lessons are learnt and positive changes made, but to compound the tragedy with lies and cover ups does an injustice to us all. All most people want to know is the truth so that they can understand what 'actually' happened.

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  • James

    Nothing will change until "managers" are held personally liable for the dysfunctional systems/services which they are responsible for.

    The system that was closed, defensive, legalistic and reluctant to learn is a system deliberately put in place and maintained by "senior" NHS "managers" .

    These people are never held to account but you already know this.

    Condolences on your terrible and avoidable loss.

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