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Change needed 'from ward to board'


Joshua Titcombe died aged nine days.

Joshua Titcombe died aged nine days.

Joshua Titcombe died aged nine days.

A father whose baby son suffered a "horrific death" following mistakes by midwives has said the family is still "haunted by the trauma of his short life" as the health ombudsman criticised the trust for "injustice".

Joshua Titcombe was nine days old when he died from septicaemia in 2008 after a catalogue of errors at Furness General Hospital, part of the University of Morecambe Bay NHS Foundation Trust.

Midwives assumed his temperature was low because the room was cold and claimed not to know a low temperature could be a sign of infection.

They failed to listen to the family's pleas for help and Joshua's observation chart went missing - a coroner later said it may have been deliberately destroyed.

In a scathing report today, health service ombudsman Dame Julie Mellor upheld three out of four complaints made by Joshua's father, James Titcombe, and grandfather against the trust.

She said change was needed "from the ward to the board" and the trust's lack of honesty in handling complaints had caused the family "unnecessary pain and further distress".

She examined emails sent by staff and midwives about the case, including one in 2009 from a midwife being investigated by the Nursing and Midwifery Council (NMC) entitled "NMC shit".

This email was sent to a wrong address and contained personal details about the family.

The trust's medical director at the time, Peter Dyer, told Mr Titcombe the email related to the ongoing NMC investigation and described it as a "comprehensive, professional account of the midwife's recollection of events".

A separate 2010 email to the head of midwifery at the time, Angela Oxley, from the trust's customer care manager said there was "good news to pass on" regarding Mr Titcombe. He had told the manager he was extremely distressed and did not want to pursue further complaints.

Ms Oxley replied: "Has (he) moved to Thailand? What is the good news?" Joshua's mother is Vietnamese.

Dame Julie said she accepted the customer care manager, who is still in post at the trust, had meant she was concerned for Mr Titcombe's wellbeing and felt his decision to "step back" from his complaints was "good news".

Dame Julie also said she said she could not go as far as to say the head of midwifery had shown racial or ethnic prejudice. But she said: "I can only conclude that, for the head of midwifery, 'good news' would have been news that (Mr Titcombe) was moving far away.

"I find that the head of midwifery's email fell so far below the standards of respect and courtesy to be expected in these circumstances that it amounted to maladministration."

Dame Julie also found the trust had published an inaccurate and misleading press release in 2011 about the NMC email incident. The trust did not write and apologise to Mr Titcombe until nearly 17 months afterwards despite its press release claiming it had apologised at the time.

Today's report also said the trust's chief executive at the time, Tony Halsall, had told Mr Titcombe the "NMC shit" title of the email had not been disclosed originally as "it was felt that not all the information was required to be disclosed under the Freedom of Information Act".

Furthermore, Mr Halsall had originally failed to disclose staff statements to Mr Titcombe despite the trust's own lawyers saying they should be released.

In response to lawyers, Mr Halsall had said he " did not want to release the statements because it was not 'in the spirit' of the way he had been trying to address" Mr Titcombe's complaint. Mr Titcombe eventually obtained the documents.

Dame Julie found the trust guilty of "maladaministration" in several areas and said Mr Titcombe had suffered "injustice" and had lost confidence that the trust would learn from his son's death.

The ombudsman did not uphold one complaint from the family that midwives had colluded before an inquest into Joshua's death.

She said: " 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.

"When serious untoward incidents happen there needs to be an independent investigation which looks at the root cause of the complaint and the role of human factors such as people and the organisation's culture.

"We expect all service providers to adopt this approach to help them understand why mistakes happen and help improve services for everyone.

"Our recommendations underline how important it is that trusts learn from complaints. This is what families want and deserve."

Mr Titcombe said the family supported the report's recommendations for change and welcomed the ombudsman's apology for the fact her predecessor had refused to investigate the family's complaints.

He 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."

Jackie Daniel, current chief executive of the trust, said: "The trust acknowledges and fully accepts the findings of the ombudsman investigations.

"There is no doubt that the trust has badly let down the family following the tragic death of their baby in 2008.

"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 way incidents and complaints are handled by the trust has changed and new governance arrangements have been put in place.

She added: "We expect staff to always communicate in ways that are appropriate and sensitive to the needs of patients. We have introduced regular training seminars for staff about the appropriate use of emails and other communications at work. The trust will respond to the recommendations in relation to this accordingly."

Cumbria Police are still investigating Joshua's death.

The trust has already admitted Joshua would have had a 90% chance of survival if he had been treated promptly with antibiotics.