The Morecambe Bay report has been published and the scramble to avoid responsibility is on. At least 11 babies and 1 mother died at Furness General Hospital because the midwives cared more about promoting natural birth and preserving their own autonomy than they did about whether babies and mothers lived or died. The midwifery administration refused to discipline the midwives involved, and the hospital was more concerned with its business status than protecting patients. A massive health care system, the National Health Service (NHS) failed in its legal and moral responsibility at every level, bottom to the very top, hiding, eliding and dissembling to protect the wrong doers initially, and eventually to protect themselves. They brought an enormous amount of bureaucratic power to bear, essentially everything they could muster, and yet they lost.
They were defeated by the power of a father’s love.
Joshua Titcombe died when, despite the pleading of his parents for 24 hours, midwives refused to call a pediatrician to care for him when he was obviously ill. They waited until he was nearly dead to call for help and by then it was too late for the help that almost certainly would have cured him had it arrived earlier. The midwives rebuffed his parents, the hospital administration tried to convince them that no one did anything wrong, and the bureaucracy of the NHS insisted that appropriate care had been provided.
But James Titcombe, Joshua’s father, refused to be put off and he refused to be silent. He was treated to stonewalling and abuse on a scale that is difficult to imagine, but he did not give up. Why? Because his love for his son was stronger than even the mighty NHS.
They say that statistics are human beings with the tears wiped off, and that’s certainly true in this case. It is important to deal with the statistics: how many died, how many midwives valued natural childbirth above safety, how many levels charged with oversight ignored their responsibilities in favor of their reputations. It is appropriate that, going forward, attention will be focused on statistics, but we should take a moment to consider the human beings and the floods of tears behind those statistics.
I first wrote about Joshua in November 2011 after being contacted by his father James (Joshua’s easily preventable, tragic hospital birth death).
[He] contacted me to share more details about Joshua’s birth and needless death. He gave me permission to share with you the presentation he created to ensure that Joshua will be remembered and that his death will serve a purpose, focusing attention on the substandard midwifery care that is the result of midwives protecting their “turf” and refusing to refer complicated cases to obstetricians and pediatricians.
James was treated appallingly by those who were supposed to search for the truth.
According to The Independent:
The family were left deeply hurt on two occasions after seeing internal email exchanges between Trust staff. One followed an email from Mr Titcombe in June 2010 saying he would be stepping back from his inquiries after “becoming extremely distressed and anxious” about the investigations progress.
Informing the Trust’s head of midwifery of the email, the Trust’s customer care manager wrote: ‘Good news to pass on re [Mr Titcombe]’, and received the reply: ‘Has [Mr Titcombe] moved to Thailand? What is the good news?’
In another email from August 2009, later seen by Mr Titcombe, a discussion of a midwife’s statement to the Nursing and Midwifery Council (NMC) concerning the circumstances of Joshua’s death was subject lined: “NMC shit”.
Despite that, James pressed ahead. In February 2014, he and his wife received an apology for the NHS Ombudsman acknowleding that the hospital had failed to properly investigate Joshua’s death and that the Ombudsman’s office had subsequently refused to investigate at all.
James was quoted at the time of the apology:
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.
The Morecambe Report on Joshua’s death and the deaths of other babies and mothers was published last week and it corroborated everything that James had claimed. The midwives DID have a cult of natural childbirth that took precedence over safety; they DID refuse to call other specialists when they were needed: they DID fail to investigate Joshua’s death and discipline their colleagues; the hospital DID cover up the midwives’ wrong doing; at every level the NHS DID ignore the concerns of the family, fail to properly investigate, and treat James contemptibly.
The Morecambe Bay report is vindication, but it does not bring Joshua back. James was once again quoted in The Independent:
I really recognise now when we talk about missed opportunities in this report, that for me means not having a six-year-old. Even after all these things were going wrong, nothing was done and patients were allowed to die.
It is very hard to forgive the deliberate covering up when it’s had such an impact…
Joshua Titcombe died a preventable death because the people who were supposed to be caring for him put their needs ahead of his needs. A family was shattered and his parents will grieve for the rest of their lives.
But though his life was short, his impact will be profound. His death was not in vain, because the failings that led to his death have been exposed and now can be addressed. His death was not in vain because his father loved him so much that he never stopped fighting for the truth.
The NHS is an extremely powerful organization. But it was no match for the power of a father’s love.
