Regulator who cleared Straw ‘let us down over baby son’s death’
THE parliamentary watchdog who exonerated Sir Malcolm Rifkind and Jack Straw has been criticised over her previous role at a regulator that was accused of failing to prevent the deaths of babies at an NHS hospital.
Kathryn Hudson was deputy head of the Parliamentary and Health Service Ombudsman (PHSO) during the Morecambe Bay hospital trust scandal, in which 11 babies died.
James Titcombe, whose son Joshua died at Furness General hospital in 2008, said he “begged” her to launch an official inquiry into what happened, but without success.
Mr Titcombe claimed that the PHSO had “lacked teeth”, was “easily influenced” and showed too much “deference” towards those it was supposed to investigate. He said Mrs Hudson’s attitude towards Mr Straw and Sir Malcolm, the two former foreign secretaries, was “very similar” to her approach to the chief executive of the Morecambe Bay hospital trust.
He went on to criticise the PHSO for “identifying with the very people they were supposed to be investigating” and being unwilling to “ruffle feathers”.
Mr Titcombe highlighted an email written by Mrs Hudson which he claimed appeared to show “collusion” between the PHSO and the Care Quali- ty Commission to protect University Hospitals of Morecambe Bay NHS Foundation Trust (UHMB).
Mrs Hudson, who was deputy ombudsman at the PHSO until 2012, before becoming the Parliamentary Commissioner for Standards, was cleared of the allegations by an independent inquiry.
She has faced criticism after ruling that Mr Straw and Sir Malcolm did not break lobbying rules in a “cash for access” scandal exposed by The Daily Tel
egraph and Channel 4’s Dispatches. It subsequently emerged she was appointed to the £108,000 per year role by a panel that included Sir Malcolm.
Joshua Titcombe died from complications caused by a lung infection aged nine days old. An inquest into his death was told he would have had a 90 per cent chance of survival if given antibiotics immediately after birth.
Mr Titcombe asked the PHSO for an investigation in 2009, fearing further tragedies could occur, but his request was refused.
Yet an independent study into the Morecambe Bay trust deaths by Dr Bill Kirkup, a paediatric surgeon, published earlier this year, concluded that “avoidable harm to mothers and babies, including tragic and unnecessary deaths […] were still occurring after 2012” at the hospital.
One mother and 11 babies could have been saved had there not been “signifi- cant” and “major failures of care” between 2004 and 2013, due to a “lethal mix of problems” at Furness General.
There was also a “disquieting” lack of oversight at the PHSO under Mrs Hudson and her boss, commissioner Ann Abraham, Dr Kirkup concluded. Mr Titcombe told The Daily Tele
graph that he believed the PHSO had “colluded with the system to let them [the hospital] off the hook”.
A memo obtained by Mr Titcombe purported to show that Mrs Hudson wrote to Ms Abraham in September 2009 about a conversation the latter al- legedly had with Cynthia Bower, then the chief executive of the CQC. It stated: “[The] suggestion arose that if we could assure Mr and Mrs Titcombe that as a result of their experiences CQC are now taking robust action to ensure improvements in the maternity services at the Trust, you might decide not to investigate.” Ms Abraham later told investigators she “would not have had an unminuted discussion with Cynthia Bower on such a serious matter along the lines suggested by [Mrs Hudson]”.
Ms Abraham also said: “I had assurances from CQC that were worth absolutely nothing and fell apart, you know, within a matter of weeks.”
Mr Titcombe was notified of the PHSO’s decision not to investigate Joshua’s death in a letter from Ms Abraham on Feb 3, 2010, four months before a snap inspection by the Care Quality Commission gave Furness General Hospital a clean bill of health. The CQC then changed its mind in September 2011, and said the unit could be closed if improvements were not made.
A coroner, Ian Smith, later accused midwives at the Trust of deliberately “losing” Joshua’s medical notes in an attempted cover-up.
The absence of these notes was later presented by the PHSO as a deciding factor in its refusal to reopen inquiries.
Ms Abraham’s letter to Mr Titcombe, marked “confidential”, said: “Thank you for allowing my deputy, Kathryn Hudson, to visit you […] and for providing her with additional information since that time, which she has discussed with me.
“I am satisfied […] lessons have been learnt and improvements made and that an investigation by my office is unlikely to achieve any more in this area.
“As you know, despite thorough searches, the records for the first 24 hours of Joshua’s life are still missing.
“The staff involved have been interviewed on more than one occasion. It is unlikely that they would now change their accounts of the events and for this reason, in the absence of records, a further investigation is not likely to reach a firm finding of what took place and why.
“Mrs Hudson and I have discussed the possibility of an investigation of the process by which the Trust investigated the events surrounding Joshua’s death, but this limited work would be unlikely to satisfy your concerns by providing the answers you seek.
“I do not want to raise expectations for you and your wife which could not realistically be met.”
Dr Kirkup cleared Mrs Hudson and Ms Abraham of allegations that they “colluded” with the CQC and UHMB to avoid the ombudsman having to be more closely involved. But his report noted: “We do, however, retain a degree of disquiet about the PHSO decision not to investigate the complaint.”
Mr Titcombe, who is now a national adviser to the CQC, resigned last week from an NHS England maternity care review citing “attacks” from midwives.
He said: “The PHSO were the only people I had to speak up for me.
“I think they let down all the other mums and babies who went on to die after Joshua died.”
Mrs Hudson said she accepted Dr Kirkup’s findings and had “made clear how decisions at the PHSO were made, both in general terms and in the specific context of Mr Titcombe’s case”, in her evidence to it.
UHMB accepted liability for Joshua’s death. The CQC has previously said its regulation of UHMB was not as “robust as it should have been”, and apologised for “missing opportunities to intervene to prevent poor care”.
‘[Health ombudsman] identified with the very people they were supposed to be investigating’