Earlier this month, after 7 years, dozens of deaths, and an extraordinary, massive cover-up effort, Cathy Warwick of the Royal College of Midwives finally acknowledged the truth:
Failures that led to a major baby death scandal could be being repeated elsewhere because midwives are not challenging poor care, the country’s most senior midwife has said.
Eleven babies and one mother died amid a “lethal mix” of failures in Morecambe Bay maternity services between 2004 and 2013, an inquiry found earlier this year.
[pullquote align=”right” color=”#333333″]The years went by, the lies mounted, but James did not give up.[/pullquote]
The report by health official Dr Bill Kirkup found a “dysfunctional” maternity unit giving substandard care, with midwives at Furness General Hospital who dubbed themselves “the musketeers” pursuing natural childbirth “at any cost”.
Yesterday the general secretary of the Royal College of Midwives (RCM) raised fears that similar failings could be going on elsewhere, without the public knowing.
Cathy Warwick told its annual conference: “The terrible truth is right now everything Dr Bill Kirkup found could be happening elsewhere and will continue to happen unless we (midwives), not just others, do something about it.”
That Warwick finally acknowledged the terrible truth is due, in no small measure, to the efforts of one man, James Titcombe, who relentlessly pursued efforts to hold providers responsible for the entirely preventable death of his only son, Joshua. James’ book, Joshua’s Story goes on sale later this week and is already sold out of AmazonUK.
The text is spare and beautiful, but it is a difficult story to read. The story of Joshua’s short life is agonizing not least because it is apparent from the very beginning that the midwives involved in his mother Hoa’s care were more concerned about maintaining control of patients than about providing lifesaving care.
The facts are brutal. Hoa arrived at Furness General Hospital deeply concerned that she had been quite ill, including a sore throat, in the days prior to starting labor. She had also been sent home with ruptured membranes 2 days prior to starting labor.* The midwives involved in her care dismissed her illness as “a virus,” but when she developed a high fever, they started antibiotics for her. Despite that, and despite the fact that Hoa and James repeatedly asked for antibiotics for Joshua and repeatedly complained that he did not seem well, and critically, despite the fact that Joshua’s temperature was profoundly below normal, the equivalent of a high fever in an infant, the midwives did not call for a pediatric evaluation.
I ask the midwives whether or not there was any risk that Joshua might also need antibiotics. The response I get back is clear and absolute.
“Joshua is absolutely fine. It’s your wife you need to be concerned about.’
‘My wife needs antibiotics, why doesn’t Joshua?’
‘The infection in Hoa is in a different system. We know Joshua is fine just by looking at him.”
When Joshua collapsed shortly before being discharged from the hospital, he was transferred to a children’s hospital where the staff fought to save his life for 8 days before he succumbed. Joshua died of Pneumococcal pneumonia, which he almost certainly caught from his mother, and which could have been easily treated with antibiotics.
After the funeral, James began the search for answers. He had no medical training, and little knowledge of the National Health Service, but he did have his training as a nuclear safety professional. He assumed, incorrectly as it turned out, that hospitals must have safety procedures just like nuclear power plants to prevent accidents from happening more than once.
He met a wall of resistance extending from the midwives themselves, through the organizations designed to supervise midwives and hospitals, right through the organizations designed to serve as guardians for patient safety. It was coordinated resistance, with multiple people and multiple organizations collaborating to whitewash not merely Joshua’s death, but, as James came to learn, many other deaths that happened both before and after Joshua’s.
At times it was Kafka-esque. The most important part of Joshua’s medical record, the temperature chart that showed his profoundly abnormal temperatures, was noted to be missing from his chart nearly immediately. This extraordinary fact was cited repeatedly by multiple organizations, not as reason to investigae Joshua’s death further, but as reason to justify NOT invesigating it since critical information was missing.
The years went by, the lies mounted, but James did not give up. He was supported along the way by the other families whose babies or wives had died and he was helped ultimately by a sympathetic few, mostly outside of the medical system, and the pressure they brought to bear led to a Coroner’s inquest.
The Coroner’s findings were shocking. He found that the midwives’ testimony was both unbelievable and the result of collusion in creating answers; that it was likely that the missing temperature information was destroyed; that there was no evidence to corroborate the midwives’ testimony that Joshua’s condition had been discussed with and dismissed by a pediatrician.
The damning conclusions generated the publicity that ultimately led to the Morecambe Bay report that looked at all the deaths that had taken place at the maternity unit. The findings were scathing:
“Our conclusion is that these events represent a major failure at almost every level. There were clinical failures, including failures of knowledge, team-working and approach to risk. There were investigatory failures, so that problems were not recognised and the same mistakes were needlessly repeated. There were failures, by both Maternity Unit staff and senior Trust staff, to escalate clear concerns that posed a threat to safety. There were repeated failures to be honest and open with “patients, relatives and others raising concerns. The Trust was not honest and open with external bodies or the public. There was significant organisational failure on the part of the CQC, which left it unable to respond effectively to evidence of problems. The NWSHA and the PHSO failed to take opportunities that could have brought the problems to light sooner, and the DH was reliant on misleadingly optimistic assessments from the NWSHA. All of these organisations failed to work together effectively “and the result was mutual reassurance concerning the Trust that was based on no substance.
Joshua’s Story will make you cry and will make you very angry. It is a testament to the power of a father’s love in the face of official negligence and massive stonewalling. Warwick’s acknowledgement that midwives bear responsibility for these and other deaths shows that James’ efforts were successful.
Nonetheless, as far as I can determine, very few if any of the many individuals involved in providing substandard care and then covering it up have been punished. Most are still working within the system despite their appalling failures. Cathy Warwick has been forced to acknowledge substandard midwifery care, but she has shown no sign that the Royal College of Midwives has taken any concrete steps to prevent tragedies like Joshua’s from ever happening again.
*Edited 11/29/15 4:20 PM.
