A “lack of openness and honesty” at University Hospitals of Morecambe Bay Trust caused further distress for a family which had lost a child, a watchdog has concluded.
Dame Julie Mellor, the parliamentary and health service ombudsman, investigated five complaints relating to the way in which the trust handled the Titcombe family’s complaints about the death of their nine-day-old baby Joshua in 2008.
The complaints investigated focused on the quality of the investigations the trust carried out into the death, inappropriate email exchanges between hospital staff, and alleged collusion amongst midwives in preparation for an inquest into the baby’s death.
The complaint about the quality of the investigations by the trust and the two complaints about inappropriate email exchanges were upheld. However, the allegation of collusion among midwives before the inquest was not upheld.
A fifth complaint against the North West Strategic Health Authority has already been resulted in the ombudsman ruling that supervision and regulation of midwifery in the area was flawed, sparking the Nursing and Midwifery Council to announce a review of the system in January.
Dame Julie said the reports “highlight the need for more openness and transparency in the way hospitals and the wider health and social care system deal with complaints”.
“In these cases the trust failed to be open and honest about what went wrong and this caused the complainant and his family further unnecessary distress at a very difficult time,” she added.
In the introduction to yesterday’s report Dame Julie wrote: “Change is needed in hospitals, in the way investigations are conducted and in the wider health and social care complaints system.”
The ombudsman has made a series of recommendations for all hospital trust boards. These include:
- Ensuring a focus on openness and honesty that rewards staff who respond well to complaints, including acknowledging mistakes.
- Organisations should commission an independent investigation if a complaint amounts to a serious untoward incident or raises issues of serious professional misconduct.
- Organisations should use the science of human factors and root cause analysis to get to the bottom of a service failure.
- The ombudsman has also signed up to the National Quality Board’s Human Factors in Healthcare Concordat. This is a pledge to increase commissioners’ and providers’ awareness of human factors and how it can be used to improve quality and safety.
The first complaint
In his first complaint, the boy’s father James said that the trust failed to adequately investigate the events surrounding the death of his son, who is referred to as baby G in the report.
He said that an external report led by three senior NHS staff from other trusts and commissioned by the Morecambe Bay in December 2008 was full of errors. Mr Titcombe - referred to as Mr D - also said that he was repeatedly told by the trust that there were no discrepancies between the statements from staff and his and his wife’s recollection of his son’s condition at birth. However, Mr Titcombe said that when he eventually obtained the statements he saw “significant differences”.
The ombudsman report said: “I find that the failings I have identified were serious because the trust had a responsibility to ensure that the circumstances of baby G death were thoroughly investigated. The trust had already acknowledged failures in G’s care and that these failings led to his death. The original failures of care were compounded by the failure to investigate properly and to answer all of Mr D’s very legitimate concerns.”
The second complaint
The second incident relates to the trust’s response to a complaint Mr D made about an email he read from a midwife at the trust, which had the subject line “NMC shit”. The email was a draft response to questions from the Nursing and Midwifery Council as part of an investigation into the midwives’ actions surrounding Joshua’s death.
The email, which contained personal information about the Titcombe family, was sent to an incorrect email address.
The trust informed Mr D of the wrongly directed email but said it constituted a “comprehensive, professional account of the midwife’s recollection of events”. Upon obtaining a copy of the email through a Freedom of Information request Mr D discovered the nature of its subject line.
Mr D complained to the trust about data protection issues and the subject line.
The ombudsman upheld Mr D’s complaint. She said that the trust had failed to tell Mr D about the exact nature of the email because, given the “offensive” title of the email, it was inaccurate to describe it as a “professional account”.
The third complaint
In the third incident Mr D complained that an email exchange between the trust’s then head of midwifery and its customer services manager was “offensive to him and his family, particularly his wife, who is Vietnamese”.
Mr D used the Data Protection Act to request a large amount of information from the trust relating to him and his family.
He discovered an email exchange which followed him emailing the customer services manager in June 2010 to say that he would no longer be contacting the trust. The customer services manager emailed the head of midwifery, referring to “good news to pass on re [Mr D]”. The head midwife replied: “Has [Mr D] moved to Thailand? What is the good news?”
Mr D emailed the trust when he discovered this email exchange. The customer services manager said she made the “good news” comment because she was concerned about the complainants’ wellbeing. The head of midwifery said that she thought Mr D was going on an extended holiday to south east Asia and, “I therefore maybe wondered if he was going to live there again”. She added that her comment had “no racial prejudice connotations whatsoever”.
In conclusion the ombudsman found that although the trust had offered an apology, “I do not consider that the trust conducted a thorough investigation of this incident”.
The fourth complaint
In the fourth complaint Mr D alleged that the trust’s staff “colluded to present false evidence” at his son’s inquest.
The ombudsman did not uphold this complaint because she found “no evidence that the trust, when preparing for the inquest, failed to comply with the law or act in accordance with established good practice and no evidence of collusion between the midwives”.
In a letter to the ombudsman in response to the draft report into the fourth complaint that the midwives colluded, Mr D wrote: “It is not fit for purpose and should be withdrawn.
“I do not now have any confidence in the ability of the ombudsman to conduct a satisfactory investigation into my complaint.”
Morecambe Bay chief executive Jackie Daniel said the trust fully accepted the ombudsman’s findings.
“There is no doubt that the trust has badly let down the family following the tragic death of their baby in 2008,” she said. “Clearly some of the actions highlighted by the ombudsman have caused further unnecessary distress and pain. This is completely unacceptable and we are truly sorry for this.”
She said the trust now had new procedures for handling incidents and complaints, as well as new governance arrangements. Incidents and subsequent investigations and action plans were now reviewed weekly by the executive chief nurse, medical director and senior clinicians.
James Titcombe said the reports made “strong recommendations for change which we support”, especially “the need for honesty and robust incident investigation following avoidable harm or death”.
“The report recommends that such investigations use human factors techniques and that training is provided to equip health care professionals with the skills necessary to do this,” he added. “This is a hugely important recommendation and one which if the NHS implements, will make a significant difference to patient safety.”
However, Mr Titcombe added: “My family and I wish to make it clear that we do not accept the ombudsman’s report in relation to how staff prepared for Joshua’s inquest.
“Joshua’s death has had an unbearable impact on our family, we miss him every day and continue to be haunted by the trauma of his short life and his horrific preventable death. The last five years have been made so much worse because of the way the trust and other organisations responded to his loss.
“Our sincere hope is that no other family in the future has to go through what we have. We welcome the recommendations made in this report which should help ensure that this is the case.”