Last week was a very difficult one for me and families like mine who suffered loss at Morecambe Bay.
The Kirkup Report set out the painful and devastating truth surrounding the serious failures at Furness General Hospital in Barrow that led to the avoidable deaths of our loved ones.
The report has triggered many emotions: deep sadness, anger and a sense of vindication. For our families this has been a long and hard journey during which we have received little support. At times we have felt vilified by the organisations that failed us so badly.
“For our families this has been a long and hard journey”
Having lost our loved ones in such horrific circumstances, instead of being helped and supported to come to terms with our loss, our agony has been exacerbated by the dishonesty we have faced. It is unforgivable that opportunities to prevent what happened to our loved ones were not taken because earlier serious incidents were covered up. It is unacceptable that after we lost our loved ones yet more lives were lost because the trust and its staff failed to be honest and learn lessons.
“The two reports together give a clear indication of how the culture of cover-up needs to change”
Now, however, we finally feel we have the full truth. This is terribly important to families such as mine who are affected by tragedies like this. The Kirkup report comes just weeks after Sir Robert Francis QC’s Freedom to Speak Up Review was published. The two reports together give a clear indication of how the culture of cover-up needs to change.
We met a system that was more interested in keeping bad news quiet than assuring the safety of the mothers and babies who used the maternity services at FGH. The chief executive at the time told people what he wanted them to hear and suppressed important reports when they pointed to serious problems.
“The chief executive at the time told people what he wanted them to hear”
In 2009, the year after the avoidable death of my son, nine-day-old baby Joshua Titcombe in FGH, I was working on a nuclear project at Sellafield in Cumbria. The project had a scheme where reporting safety issues was actively encouraged. Each month, if the number of safety issues raised by staff was more than 100, someone would be nominated by the safety team to win an iPad for the “best” safety issue reported.
In annual appraisals staff were asked about an issue they raised and what action they took. Reporting safety issues was seen as vital to professional behaviour, and something for which people were rewarded.
The culture in healthcare is very different and it is a real problem. Dr Kirkup and Sir Robert Francis QC’s whistleblowing review lay bare the deep cultural issues that still infest too many parts of the NHS. Sir Robert’s report provides a clear diagnosis of the problem and makes recommendations that will represent an important step forward for cultural change across the NHS.
If this happens, 2015 will mark another key turning point for the NHS and a step closer to the kind of culture I experienced working in the nuclear industry. This will not happen overnight. Patients, staff, regulators, professional bodies and NHS leaders will need to work together. It will take a sustained effort.
“The families of Morecambe Bay hope that the publication of the Kirkup report will lead to sustained effort and change”
The families of Morecambe Bay hope that the publication of the Kirkup report will lead to sustained effort and change, and cross-political support for the drive to improve patient safety and culture in the NHS which Jeremy Hunt has initiated.
We are pleased that a full national review of maternity services in England will take place and we hope this leads to improvements in the safety of maternity services nationally. If this happens, while nothing can bring our loved ones back at least we will be assured that their loss was not in vain.
James Titcombe is national adviser on patient safety, culture and quality at the Care Quality Commission