I was invited to speak at James Titcombe’s book launch a few weeks ago and I can not stress what a huge privilege it was to be a part of that event, and James’s story – but also what a huge responsibility it was.
James wrote the book Joshua’s story after he lost his baby son because of care failings at University Hospitals of Morecambe Bay Trust.
The book tells the story of the horrific negligence and lack of competence of the midwives caring for Joshua in 2007 and how the baby died at just a few days old as a result of what happened at Morecambe Bay.
But more than that, it tells the story of how clinicians, managers, regulators and policy leaders covered up what had happened – obscuring the truth and making it harder for James and his family to understand what had occurred and make peace with it. At a time when he should have been finding peace to cope with his grief, he was having to make requests for information, push the ombudsman to investigate, and deal with constant lies and deception from senior staff at the hospital, and most of the people who should have been responsible for holding the organisation to account.
”At a time when he should have been finding peace to cope with his grief, he was having to make requests for information”
Since the tragedy, James has left his job and now works at the Care Quality Commission to try and improve the system he has been let down by in the worst possible way.
That takes some courage, but his experience and his ability to vocalise it could – and definitely should - change the NHS forever.
Secretary of State for Health Jeremy Hunt was at that same book launch, and I’ve no doubt that he takes patient safety very seriously and wants to put patients first. But he must be honest, I think, in recognising that the bureaucracy, the penny pinching and the understaffing in our NHS’s wards and units put that safety at risk.
There was a time when the Francis effect felt like it had given nursing a moment – a moment to prove its value, to prove what it needed to provide great care. It was a time when the politicians, the media, the public and everyone realised the impact of nursing cuts and knew that care would suffer if targets and finances were put first.
”There was a time when the Francis effect felt like it had given nursing a moment”
In the last few days of 2015, we saw Southern Health and Stafford Hospital at the centre of attention for delivering unacceptable care. At Stafford a three-year-old boy’s death saw the hospital once again at the epicentre of scrutiny.
“I consider that problems of a closed culture within the NHS continue to exist. Expectation of blame leads to defensive behaviours. There should be an expectation within NHS organisations that they will openly cooperate with reviews of care performed within the NHS,” according to Dr Farrier, an associate medical director at Wrightington, Wigan and Leigh Foundation Trust, who conducted the independent investigation, which criticised the Mid Staffordshire Trust.
The Trust was, of course, dissolved in 2014.
We’ve attempted to normalise the process of raising concerns in the healthcare landscape, through our Nursing Times Speak out Safely campaign, but when we hear the stories of James Titcombe and those of the parents of Jonnie Meek, the three-year-old who died at Mid-Staffordshire Hospital, you realise the enormity of the problem.
So if I had one wish for the NHS and healthcare in every setting in 2016, it would be that everyone in healthcare does learn. Every clinician could start by reading Joshua’s Story – to understand how it feels to lose someone and then be lied to about it.
This book makes crystal clear that every word they say – or don’t say – as well as every action they take or omit can have the most enormous consequences. And sometimes doing the right thing is the easiest thing to do.
Many things that happened to the families in this book can not be excused. But we must learn from them.
I agree with the quote that James uses to head up Chapter 18 in his book. It’s from Sir Liam Donaldson and says: “To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.”
That is something we should all bear in mind in 2016. Mistakes will happen, especially under the sort of pressure that most clinicians work in. But to fail to act decently afterwards is indefensible. It really is time to own up when we mess up, and start to make the NHS safer for all.
You can buy a copy of James Titcombe’s book at the Patient Stories Website