Why are they still delivering babies today... seven years after my Joshua’s death?
IT WAS a story that shocked the nation when, in 2011, The Mail on Sunday revealed how police were investigating the deaths of babies at an NHS maternity unit – and that midwives may have covered up mistakes by destroying medical records. One of the victim
OUR world has been torn apart. Within the space of a few hours I have gone from the anticipation and joy of preparing to take home my healthy newborn son to being faced with the possibility that he could die, or survive with a serious disability.
We know that Joshua’s condition is serious, because he’s struggling to breathe, but no one can give us a clear picture of what is wrong. Although we don’t know it at the time, our baby boy has a common infection – the same one my wife, Hoa, had been treated for with antibiotics when she became unwell after giving birth.
Critically, we were firmly told by midwives, our son did not need the same medication – a simple jab. ‘Joshua is absolutely fine. It’s your wife you need to be concerned about,’ I was told.
When I queried why Hoa needed antibiotics but Joshua did not, I was told: ‘The infection in Hoa is in a different system. We know Joshua is fine just by looking at him.’
With hindsight, as Joshua’s condition deteriorated, instinct was telling me that what we were told – that there was nothing to worry about – did not feel right. But I am just a dad, what did I know?
The next morning my wife finds Joshua is blue and barely breathing in his cot. She calls for help and he is taken to see a doctor. I get to the hospital to be told Joshua needs to be fully ventilated, and I am asked to leave the room. My father arrives. He and I hug and we both cry. A young midwife looks at us, shakes her head and tuts: ‘Haven’t you been through anything like this before?’
‘No,’ I reply. ‘I haven’t.’
I WANT TO SCREAM
A DAY after he is born on October 28, 2008, Joshua is transferred from the Special Care Baby Unit at Furness General Hospital (FGH) in Cumbria by ambulance to St Mary’s Hospital in Manchester. I tell the transfer nurse that Joshua had been very cold, and needed to be repeatedly heated. I told him I had been reassured that this meant he didn’t have his mother’s infection.
‘A low temperature is a classic sign of infection in newborn babies,’ he tells me. I’m stunned. Why hadn’t someone referred Joshua to a doctor and given him antibiotics earlier? From that moment, I am acutely aware that something has gone very badly wrong at Furness General Hospital. I want to scream as loudly as I can and demand answers, but our focus has to be on Joshua. More than anything, we want him to pull through.
Tests show that he has an overwhelming pneumococcus infection, the same infection that Hoa had collapsed from shortly after his birth.
The team in Manchester are able to stabilise his oxygen levels but he is on maximum life support. The ventilator is turned up as high as possible, and this is putting pressure on Joshua’s heart.
The only other option is ‘ECMO’, which stands for Extra Corporeal Membrane Oxygenation. This involves taking the blood outside the body through a series of tubes, and then around a machine that does the job the lungs normally do to oxygenate it. We hope it will allow Joshua’s lungs to rest and recover.
IN TEARS, WE LET HIM GO
JOSHUA is transferred by air ambulance to the Freeman Hospital in Newcastle, one of the few specialist centres in the UK that provide ECMO. When we next see him, he is cocooned in wires and tubes with electrode patches, each printed with a teddy bear’s face. He is under a lot of sedation so his eyes are closed, but if you put your finger in his hand, he grips it like babies do. This is how Hoa and I see Joshua for the next seven days. We desperately want to pick him up and cuddle him.
For five days, things seem positive. On November 3, the consultant decides his lungs have improved sufficiently for him to be weaned off ECMO. But Joshua’s left lung is more severely damaged by the infection than was previously realised. During the weaning process, his left lung starts to bleed from an area that had become necrotic – cells in the lung tissue had died. The bleeding is profuse and unstoppable. We are told it might be possible to operate to remove the necrotic lung but to do so would be futile and only serve to extend Joshua’s suffering. In tears, we agree to let him go. I beg the doctor to make sure that he isn’t in any pain. At exactly 12.15pm, he comes back into the room and tells us that Joshua has gone. I have never felt such agony or grief, but worse still is seeing my wife’s pain. The emptiness and sorrow on her face are unbearable. The staff at the Freeman Hospital are kind and caring. They tell us that Joshua will be stitched up and we can then hold him for the last time. We let our daughter Emily, then three, come with us; this is her brother and we want the family to be together. This is the first time we have seen Joshua without the tubes, wires, patches and the rest of the equipment that surrounded him since the day after his birth.
He looks like a perfect, beautiful baby boy. We take it in turns to hold him, kiss him, tell him how much we love him and how sorry we are. And then we have to say goodbye.
RECORDS GO MISSING
YOU don’t get over the death of a child. All you can do is build your life around it. As the first wave of grief subsided, I knew I had to find out what had happened to Joshua. After asking to see his medical records, at the end of November I was told by the hospital’s customer services manager that the observation chart on which his temperatures were recorded was missing. Tony Halsall, chief executive of University Hospitals of Morecambe Bay NHS Trust, which FGH was part of, assured us Joshua’s death would be fully investigated by the Trust and the Local Supervising Authority (LSA), which oversees midwives.
ADMISSION OF FAILURES
BY DECEMBER I was back at work. I was a project manager in the nuclear industry. In early January 2009, we learnt that Hoa was preg- nant. The mix of emotions was hard to explain: joy, guilt and sadness.
I started to research more about what happened to Joshua online. Streptococcal pneumonia, or pneumococcus, which is the infection Joshua had, is rare and aggressive, and associated with pre-labour rupture of membrane. (After Hoa’s waters broke, we had gone to hospital immediately, but were then sent home as contractions hadn’t begun and didn’t for two days).
In February 2009 we were given the conclusion of the internal investigation by Halsall, personally. This was the first of many – from just about every public body from local to national level – none of which seemed to answer our most basic question: why did Joshua die?
Halsall admitted to monitoring
failures that led to antibiotics being ‘started later than they could have been which may have contributed to the eventual tragic outcome in the case’. But the report stated: ‘There is no mention of Mrs Titcombe being unwell in the days prior to delivery.’ In fact, my wife and I had had detailed discussion with staff about not feeling well before the birth. We’d all been suffering from sore throats and headaches.
REPORT WHITEWASH
THE LSA report, given to me in June 2009, was a total whitewash. They had apparently found some of Joshua’s observations, which recorded the ‘fluctuations in [his] temperature were between 36.4C and 36.8C’. They called this varia- tion in temperature ‘normal’. Hoa clearly recalled seeing a temperature on Joshua’s chart of 35.8C. The LSA version of events was simply not true.
They also claimed: ‘Midwives A and B have no recollection of a sore throat being reported to them.’ In fact, a midwife had told us Hoa’s illness ‘was probably a virus’ and that there was ‘a lot going round’.
Midwives also claimed they bleeped a doctor from the Special Care Baby Unit – but didn’t take down his name – and advised that Joshua should be observed. It was later revealed that switchboard logs did not verify this. So this statement was false. I was outraged by the midwives’ dishonesty. It felt as if they only wanted to sweep what had happened to Joshua under the car- pet. I was not dealing with a tragic accident, but a deliberate cover-up.
WE ARE NOT ALONE
ON JULY 3, 2009, our local newspaper ran a story headlined ‘Coroner slams Barrow hospital over stillborn baby death’. The report was about the tragic death of Alex Davey-Brady at Furness General, just months before Joshua had died. The words of the coroner – ‘the midwives ran the show’ – echoed in my mind. The phrase perfectly described what had happened to Joshua. We now knew his death was not an isolated incident.
In September, Hoa went into labour. Our consultant strongly advised against having the baby at either Kendal or Lancaster as the hospitals were too far from our home. Instead, we were offered a special plan of care at FGH.
After Jessica was delivered, she was transferred, as planned, straight to the Special Care Baby Unit. I watched as she was given a precautionary antibiotics injection. It took only a few moments. I felt a deep sadness that Joshua had been denied such a simple procedure.
FINALLY, THE TRUTH
THE Kirkup Report, an independent inquiry into deaths at the maternity unit at FGH, was published on March 3 this year. It marked the end of five years of ceaseless campaigning by me and other families whose babies had died. We wanted to know why what had happened to us had happened. And we wanted to be sure lessons had been learned.
The organisations involved, from the NHS Trust and the LSA, to regulators the Care Quality Commission (CQC), Monitor, the Nursing and Midwifery Council (NMC), the Health Service Ombudsman, and the Department of Health had all failed the public they were supposed to care for and protect. If any one of them had acted when I first contacted them, I have no doubt lives would have been saved. Instead I was dismissed, lied to so many times, and accused at various times of being a vengeful, grieving father, self-aggrandising, deluded and an irritation.
One of the midwives had emailed a report about Joshua’s death that she was preparing for the NMC to a colleague, and titled the email ‘NMC S**t’. Joshua’s death seemed to mean so little to the staff who let him down. Losing our son was an agony beyond words. But what happened after, the way in which we were treated, beggars belief.
The day before the report was published, I attended a meeting in Barrow with Dr Kirkup to learn what he had found. There were many other families there. Finally, we were to be told the truth.
Dr Kirkup described the maternity unit at FGH as ‘seriously dysfunctional’, with a culture among midwives of pursuing normal childbirth ‘at any cost’. This and other factors combined to create a ‘lethal mix’: the investigation found 20 instances of ‘major failures of care’ associated with the deaths of three mothers and 16 babies dating back to 2004.
There were missed opportunities to intervene at almost every level of the NHS. This included the Strategic Health Authority, the CQC, the Health Service Ombudsman and the Department of Health.
The reactions from staff ‘… were shaped by denial that there was a problem, their rejection of criticism… that they felt was unjustified (and which on occasion, turned to hostility) and a strong group mentality amongst midwives characterised as “the Musketeers”’.
. . . BUT STILL NO JUSTICE
THE next day I went to Joshua’s grave a short walk from our house. I still feel we are yet to have justice for him. Not a single midwife involved in his care has faced any kind of sanction over Joshua’s death (the NMC are still investigating the conduct of five involved in his care) and all are still employed at the hospital where he was born.
More than seven years after our precious baby died, with the help of brave families, the media and some key individuals who went against the prevailing tide to provide support, we finally managed to make sense of the events that led to the loss of so many innocent lives.
But it couldn’t change the one thing in the world I wanted. It couldn’t bring Joshua back.
Joshua’s Story, by James Titcombe, is published by Anderson Wallace. Order your copy for £8.99 (normally £10.99) from patientstories.org.uk.