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Tuesday, 22 July 2014

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NHS trust caused Barrow family ‘unnecessary distress’

A GOVERNMENT watchdog has ruled a hospital trust caused a grieving family “unnecessary and unjustifiable” distress in its handling of an incident.

The health service ombudsman has demanded the University Hospitals of Morecambe Bay NHS Foundation Trust apologise and pay compensation for a series of failures and errors which led to further anguish for the Titcombe family, who lost their son Joshua.

It comes following the completion of an investigation into a complaint over the trust’s actions after midwives at Furness General Hospital sent an offensively-titled document, relating to the Titcombe case and containing confidential patient details, to an unknown email address.

Nine-day-old Joshua died after staff failed to spot he had contracted an infection in 2008. A probe was launched after his father, James Titcombe, lodged an official complaint.

In 2009, he was contacted by the hospital trust to notify him of a breach of data regulations.

The trust’s medical director, Peter Dyer, told him midwives had shared passwords to access a UHMBT computer and accidentally sent an email referring to the Nursing and Midwifery Council’s investigation into Joshua’s death to an unknown address.

Mr Dyer assured Mr Titcombe the contents of the email were a “comprehensive, professional account of the midwife’s recollection of events and nothing more”.

But when Mr Titcombe was sent a redacted version of a report into the incident in January 2011 after a request for more information, the redactions disappeared at the click of a mouse and revealed the email was entitled “NMC Shit”.

When the story was reported in July last year, the trust released a statement which claimed its then-chief executive, Tony Halsall, had written to apologise at the time of the incident, but he did not do so until 17 months after the email was sent.

Mr Titcombe complained to the ombudsman over the way the UHMBT handled the incident and an investigation was launched in December. He also raised concerns over why the trust only decided to inform the NMC after he notified them of what happened himself.

The ombudsman has found Mr Titcombe had suffered injustice at the hands of the UHMBT, as it had failed to be “open and accountable” across the three areas of complaint.

James Johnstone, director of health investigations at the ombudsman, said: “Both the trust’s initial response and subsequent handling of Mr Titcombe’s complaint fell so far below the applicable standard as to amount to maladministration.

“The trust’s actions since Mr Titcombe was informed of the emails’ disclosure have unnecessarily and unjustifiably caused him further distress.

“Even with the benefit of hindsight, all of the identified shortcomings were eminently avoidable and have served to worsen a situation caused by the inexplicable sending of an insensitively-titled email.”

Mr Titcombe said: “The ombudsman’s report confirms the trust have been dishonest with our family about this incident from the start.

“We were given a false reassurance by the trust’s medical director that the email was ‘purely professional’ and when we eventually discovered the truth, the trust did not respond to our complaint in an ‘open and accountable’ way.

“Even the press statement released when the ombudsman investigation was launched was simply not true.

“We welcome the ombudsman’s report and hope it sends a clear message to the trust’s management that they simply can no longer treat people in this way.

“My family and I still cannot comprehend how anyone involved with the preventable death of a baby boy could title an email relating to what happened, ‘NMC Shit’.

“We are left wondering how many other incidents like this have been swept under the carpet and how many other families have been misled in a similar way by the trust.”

Tim Bennett, acting chief executive of the UHMBT, said: “Whilst we understand this to be an isolated incident, we do feel it was unacceptable and only added to what was an extremely difficult time for the family.

“The matter was investigated and dealt with in accordance with internal disciplinary procedures.

“We would like to once again offer our sincere apologies to Mr and Mrs Titcombe for the additional distress and upset caused by the email and our poor handling of his complaint.

“We have started to address recommendations raised by the ombudsman and will complete the action plan within the required time frames.”

Timeline of events in crisis facing hospital services

THE Evening Mail looks back at the events which have rocked University Hospitals of Morecambe Bay NHS Foundation Trust.

October 2008: Joshua Titcombe, the son of Dalton couple James and Hoa Titcombe, dies in a Newcastle hospital, nine days after being born at Furness General Hospital. Midwives at the Barrow hospital failed to detect Joshua had picked up an infection treatable with antibiotics.

August 2010: An independent review into maternity services at FGH and Royal Lancaster Infirmary, commissioned by the trust, is published. The Fielding report claims relationships between doctors and midwives were “dysfunctional” and says FGH facilities were not “entirely fit for purpose”, in relation to the labour ward environment.

October 2010: Improvements to maternity services reduce its risk rating to ‘amber’.

June 2011: An inquest into Joshua Titcombe’s death is held at Barrow Town Hall. South Cumbria coroner, Mr Ian Smith, pinpoints 10 key failings in Joshua’s care. He also accuses midwives of “colluding” with each other over mistakes made in the care.

June 9, 2011: Cumbria Constabulary confirm a police investigation had been launched into Joshua’s death before the inquest began.

July 2011: The CQC carries out unannounced inspections of maternity services at FGH and Royal Lancaster Infirmary.

September 9, 2011: The CQC warns maternity services at FGH could close if they are not brought up to scratch.

September 10, 2011: Police confirm they have extended their investigation to involve “a number” of deaths at FGH.

September 16, 2011: The trust announces the CQC has given it a deadline of November 21 to improve services.

October 12, 2011: Government health watchdog, Monitor, orders top-level reviews into maternity and governance at Furness General Hospital to ensure patient safety.

November 21, 2011: UHMBT says it is confident it has carried out all of the actions identified in the CQC review.

November 21, 2011: UHMBT chief executive Tony Halsall says he will not quit, after a call for his resignation from an anonymous consultant working within the trust.

December 24, 2011: Mr Halsall apologises to patients and staff in a festive message to mark the end of a year which he described as the “most difficult” of his career.

January 17, 2012: The CCQ announces it is to carry out another investigation, this time into emergency care provision at UHMBT.

January 30, 2012: Mr Halsall admits the trust made an “error of judgement” when it failed to share the results of its internal ‘Fielding Report’ review.

February 7, 2012: Government regulator Monitor issues three damning reports on the UHMBT, relating to FGH maternity services, the Barrow hospital’s outpatients appointments system and the trust’s governance. It commands a shake-up of the UHMBT board, drafting in top external healthcare professional, Sir David Henshaw, to guide the trust to recovery.

February 11, 2012: The parents of three babies who died after problems at FGH make a fresh call for Mr Halsall to resign.

February 24, 2012: Chief executive Tony Halsall resigns from the trust. Finance chief Tim Bennett steps in to fill the role on a temporary basis.

March 2012: The trust is issued with two fresh warning notices over its monitoring of patients and mixed sex accommodation. The Care Quality Commission demands immediate improvements to standards of care in both areas after a number of observations from inspectors investigating emergency care pathways at the Barrow hospital and sister site Royal Lancaster Infirmary uncovered more problems.

Have your say

Mr Titcombes admirable efforts have hopefully helped prevent another family experiencing such awful negligent care again.

This was an extremely sad preventable loss of precious life due to lack of care. However, he has been instrumental in improving the care for future mothers and babies on FGH maternity ward. Well Done!

I was really upset when I had my baby, at the poor standard of care delivered by some of the midwives on the maternity ward. Some were very uncaring and unfriendly.

The maternity ward at FGH has been desperately in need of dramatic changes for years.

Posted by Well Done Mr Titcombe on 14 March 2012 at 19:07

The story above and the comments made by Bruce perfectly display the twisted mentality that exists in some areas of the NHS. I think Mr Titcombe has shown great restraint under what must have been a very frustrating and upsetting time. I do wonder now what will become of those involved in the lies told to him?

Posted by Andrew on 14 March 2012 at 10:15

View all 6 comments on this article

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