‘Clear signs’ of mistakes in maternity care being repeated, bereaved father says
There are “very clear signs” that mistakes in hospital maternity care are being repeated, a bereaved father affected by the Morecambe Bay scandal has warned.
James Titcombe told the Commons Health and Social Care Committee that bereaved families were acting as the “canary in the mine” to raise the alarm around shortcomings in care.
His son Joshua died after midwives missed chances to spot and treat a serious infection nine days after he was born at Furness General Hospital in 2008.
A 2015 inquiry found a “lethal mix” of failures at University Hospitals of Morecambe Bay NHS Foundation Trust led to the unnecessary deaths of 11 babies and one mother between 2004 and 2013.
@JamesTitcombe reflects on changes since Joshua's care at Morecambe Bay – he says that some improvements have been made but others are repeating themselves. Families are still having to act as the 'canary in the mine' for problems, rather than them being picked up by the system
— Health and Social Care Committee (@CommonsHealth) November 3, 2020
Asked if things had improved since the inquiry, Mr Titcombe said there had “certainly been some major changes”, such as setting up a maternity investigations programme.
But he added: “While saying things have changed, there are very clear signs that things are repeating.”
Bill Kirkup, who led the investigation into failings at Morecambe Bay, has been appointed to carry out an independent review into East Kent Hospitals University NHS Foundation Trust following a series of baby deaths.
A separate inquiry into maternity services at Shrewsbury and Telford NHS Hospitals Trust, led by Donna Ockenden, is under way, looking at more than 1,800 serious cases.
“When I look at Shrewsbury and Telford, and East Kent, and some of the information that’s coming about those services, they are very, very similar to issues that we found at Morecambe Bay,” Mr Titcombe said.
“It tends to be, yet again, the families involved in those cases who have acted as the canary in the mine and raised the alarm, rather than the system.
“So I do think there is some progress but also a very long way to go before we have truly learnt the lessons from Morecambe Bay.”
He referred to the Cumberlege review – into hormone pregnancy test Primodos, anti-epilepsy drug sodium valproate and pelvic mesh – which recommended appointing an independent patient safety commissioner.
“In terms of that particular recommendation, the patient safety commissioner recommendation, I think that would be one potential solution,” Mr Titcombe told MPs. “Because that would be somewhere where families could go, really ensure that their voices are heard.”
The committee heard evidence from other witnesses on the safety of maternity services in England, including from Helen Vernon, chief executive of NHS Resolution, which provides expertise to the NHS on resolving concerns and disputes.
She said around 50% of cases dealt with by NHS Resolution do not result in a compensation payment, meaning there could be relevant information to learn from mistakes that is missed.
“We only see the tip of the iceberg, with lawyers generally only putting forward every one in 10 cases that they see,” Ms Vernon told MPs.
“So there’s an awful lot of information there which is relevant but hasn’t resulted in a compensation claim.
“We only see the thin end of the wedge, we don’t get to see the many, many incidents which would happen, or the near-misses that happen, in the NHS, which don’t come to us to claim.”
