Joshua's story -_dr_amy2_-_2011Presentation Transcript
Furness General Hospital Safety of Maternity Services June 2011
In 2008, baby Joshua Titcombe, died a “needless and horrible” death due to failures in care at Furness General Hospital (FGH).
This presentation has been prepared by Joshua’s Dad, James Titcombe in order to tell Joshua’s story in full.
Furness General Hospital (FGH) Maternity Services - 2008
‘ Maternity services undertook an external assessment of patient safety and risk management in March 2008 and achieved top marks. The assessment, conducted by CNST (Clinical Negligence Scheme for Trusts) found that the Trust achieved 100% in four key areas including the treatment that mums and their babies receive during their stay in hospital. Head of Midwifery, Angela Oxley, comments: “We’re absolutely thrilled to have received such a fantastic result which is a credit to the dedication and hard work of our staff. This should reassure mums to be and their families that we adhere to robust clinical guidelines and that they are in safe hands whichever hospital they choose to give birth in .” During the assessment, the Trust was highly praised for its staff training and development and its communication to staff and service users, which ensures that everyone is aware of new guidelines, treatments and medication. Full marks were also given for record keeping, implementation of risk management strategies and the department’s organisation and learning from experience.’
- UHMB Annual Report 2007/2008
Known Serious Untoward Incidents (SUI's) before Joshua’s birth in 2008.
April 21st – Death of Niran Aukhaj and her baby
July 31st – Death of Nittaya and Chester Hendrickson
September 6th – Death of Baby Alex Brady
In total, 5 lives were lost at FHG maternity unit in 2008 following Serious Untoward Incidents before Joshua was born.
April 21st – Death of Niran Aukhaj and her baby
Mrs Aukhaj should have seen Mr Misra, but sadly for reasons nobody can explain that never happened. “She should have seen him but did not and now there is no record of a urine sample having been taken or blood pressure reading” – Coroner, Mr Ian Smith.
Husband Jay Aukhaj said: “After she was with the diabetes team she was told to go home by a member of the hospital staff and they said they would see her next time.” – NW Evening Mail
July 31st – Death of Nittaya and Chester Hendrickson
“ I told the midwife and said we need a doctor, but she said: ‘It was only a faint, we don’t need no doctors here, me and Nittaya are going to deliver this baby.’ – Carl Hendrickson – North West Evening Mail
“ Amniotic fluid embolism, particularly if the collapse happens in a well-equipped unit, should now be considered a treatable and survivable event in the majority of cases” –CMACE report 2011
September 6th – Death of Baby Alex Brady
“The midwifes ran the show” – “The doctors didn’t integrate” – Coroner.
Mrs Brady’s husband said “he felt there was a terrible lack of communication between the doctors and midwives” – North West Evening Mail.
Dr Misra’s letter of 17th October 2008 regarding Alex’s death :
“ I don’t think it is the place of the midwife to refuse once they have called the registrar/middle grade because of their concern to prevent them from any further obstetric decision making”
“ I do not think one can defend in any court of law when you have not heard the foetal heart with the Doppler and explaining that the foetal heart is normal but we are unable to pick it up because of the positioning.”
“ This has happened in our unit in the past and I am sure if we don’t take appropriate precautions and positive steps, I am sure that this is going to happen again in the future ”.
Mr Smith said:
“ Rather than one team working together, he pictured two teams operating side by side” – Coroner Ian Smith
Joshua’s Story 27/10/08 – 05/11/08 ‘ Our Little Fighter – Always Remembered ’
We found out Hoa was pregnant in early March 2008. We were ecstatic, we’d been trying for our second baby for over a year and so the news was very welcome.
Shortly after, we went to our local GP, he calculated that the baby would be due on 21/11/08. We waited nervously for the 12 weeks scan, hoping that everything would go smoothly.
Fortunately, everything went well. We had the 12 week scan and Hoa’s due date was changed to the 14/11/08.
The rest of the pregnancy was perfect, as the due date grew closer, we got more and more excited. We found out we were having a boy and decided to call him ‘Joshua’ – this upset our 3 ½ year old daughter who wanted to call him ‘John’!
As the due date approached, we all got excited. Hoa filled the house with so many baby clothes and toys, Granddad and Nana joined in the flurry of baby related talk and purchasing!
Our daughter Emily was excited too, often asking ‘When will baby John pop out?’ and we always replied, ‘in time for Christmas’.
Hoa left her job, I planned my paternity leave and saved my holidays up so I could have 3 weeks at Christmas….. We really couldn’t wait for what we hoped would be a very special Christmas time.
The Days Before the Birth…..
Monday 20 th October was to be the start of a week we would never forget. We were both feeling really poorly, we had headaches, sore throats and felt generally tired and ill.
I left work on Friday 24 th very glad when the weekend finally arrived.
On Saturday night, at about 9pm I heard Hoa shouting in the bathroom. When I went to see what was wrong, she told me she thought her waters had broke.
This was nearly 3 weeks away from her due date. I phoned my parents very soon afterwards and my mum told me about the risk of infection and that Hoa would almost certainly have the baby within 24 hours. My mum also advised us to phone the hospital which we did. We were told to go in that night.
Earlier in the week, Hoa had had a test for a suspected urine infection, and my mum reminded us to make sure we mentioned this to staff as well as how ill Hoa had been feeling.
Pre-labour At the maternity unit, we told the midwife that Hoa was feeling unwell and described the symptoms clearly. We were very anxious about infection and we discussed these concerns with the midwife. Hoa was in tears and unable to speak and I did most of the talking. We were told that the illness was most likely a virus, and that there was “a lot going around”. After being checked over, we were given advice regarding monitoring temperature at home and to keep an eye on the colour of the fluids. Hoa was discharged about an hour later and told to return anytime after 10am the next day. With still no sign of labour, at about 11.30am on Sunday 26th, we returned to the hospital. We explained that Hoa was still feeling ill, tired and had a sore throat and headache. At the hospital, Hoa was monitored for contractions (still none) and given blood pressure and temperature checks. We were later discharged and told that if the contractions hadn’t started earlier to come back on Monday morning.
Hoa started to have painful contractions at about 5.30am. We phoned the ward and were told to wait until the contractions became more regular and intense. This seemed to happen very quickly. At about 6.15am we phoned and informed the ward that we were coming in.
We arrived at Furness General at about 6.30am. The contractions were very painful and intense. At 7.38am, Joshua was born.
When Joshua was born, he seemed at first to struggle with his breathing. He was blue and limp and didn’t cry. He was taken to a table at the side of the bed and his chest rubbed. When he didn’t respond to this, the midwife and I went with him to administer oxygen. With oxygen, Joshua’s condition improved, he let out a cry and went pink. We were ecstatic. Our son appeared to be a perfect healthy boy.
Soon after the birth, at around 8am, Hoa collapsed with pyrexia, caused by an infection (later confirmed to be pneumococcus). Her blood pressure also collapsed. We were left in the room alone at the time, and after I while, I took Joshua in my arms and went out into the labour ward to ask for help.
Hoa was eventually given fluids and antibiotics.
Whilst Hoa was recovering on the bed, my concern for Joshua was immense. I repeatedly asked if he needed to be on antibiotics. I was very surprised to be told that he didn’t. This seemed counter-intuitive to me but I had no choice but to trust what I was told. The midwifes were totally dismissive that anything could be wrong with Joshua.
Still in the Labour Room…..
Hoa seemed to recover quite quickly. Within a couple of hours she was able to talk again and focus on our baby boy. We were both very concerned. We repeatedly asked why he didn’t need antibiotics and were constantly reassured that he seemed fine and there was no reason to give them to him.
Hoa was very anxious about the baby. She was so concerned that she repeatedly asked if she could hold the baby and if there was any chance the baby could catch her illness. To this she was re-assured.
We were transferred to the maternity ward at about 12am.
At just before 3 pm, we were told that Hoa could breast feed our son. Following this, Hoa had some help to try and get him started. Joshua appeared very reluctant to take the breast. He was breathing very poorly (quickly & wheezing a lot) and there was a lot of saliva bubbles around his mouth. These concerns were raised with staff but we were reassured that this was normal.
Throughout the day and night we were told that Joshua’s temperature was too low. On at least 3 occasions he was transferred to a different cot with some form of heating.
At one stage, an overhead electric heater was placed directly above Joshua for some time. Hoa and I clearly recall a midwife feeling Joshua’s skin and in response to how hot Joshua was, quickly pulling the heater away.
During each period of heating, Joshua’s temperature recovered only to drop again when he was returned.. It is important to note, that during the afternoon, Hoa remembers knocking the observation chart of the table and seeing 2 temperatures recorded. These were 35.8 o C and 36.1 o C.
I was re-assured because we thought that if Joshua had an infection, his temperature would be higher and not lower. Before I left for the night, a member of staff reassured me that this was the case.
In the early hours of the morning (around 2am), Hoa was so worried about Joshua’s breathing, which was so laboured he was ‘grunting’ she called the emergency bell by her bed for help. Joshua was taken out the room for over 30 mins and looked at by the midwifes who reassured Hoa yet again, that Joshua was fine. A paediatric review was not requested.
The First Photo… Emily meets her brother for the first time at just after 3pm on 27/10/08…….. We are all elated.
Still on the Postnatal Ward
Joshua remained in the care of the postnatal ward until 25 hours following his birth.
At this time, Joshua had never been seen by a paediatrician.
25 hours after his birth, my wife spotted Joshua collapsed in his cot, blue with bubbles of saliva around his mouth.
She called a midwife for help and Joshua was taken away. His battle for life then started.
After Joshua’s Collapse
I received a phone call from the maternity ward at around 9am and was told that Joshua was having problems and that my wife was very upset.
When I arrived, Joshua was breathing with his own lungs. Whilst we were in the room with him, he sharply deteriorated and was transferred to full ventilation.
We were told that our son had most likely collapsed due to a heart defect and he was being treated with heart medication and antibiotics.
We were then told that Joshua had a defective oesophagus as his feeding tube could not be inserted. The Barrow consultants explained that he would be transferred to Manchester St Mary’s for an operation as this was a specialist paediatric surgical centre. Once the St Mary’s transfer team took over, they soon established that his oesophagus was fine. At this stage, it was explained to me that as Barrow had only 2 intensive care cots, the transfer to St. Mary’s should continue anyway.
Transfer to St Mary’s
The St Mary’s transfer team arrived. They took about 5 hours to try and stabilise Joshua. He was in a very serious condition.
He had collapsed due to overwhelming infection in his lungs and sepsis (pneumococcus), the same organism found in Hoa.
The transfer team had to use maximum conventional life support to keep Joshua alive.
Before taking him to Manchester, we were told that his oxygen levels had been so low that there was a possibility of brain damage.
Joshua was transferred by Ambulance to Manchester later that night
In our exhausted and devastated state, despite the pain Hoa was in following birth, there was no transport arranged for us and we had to drive to Manchester in the early hours of Tuesday morning. We cried all the way and I was barely able to drive. Granddad and Nana looked after Emily.
At Manchester, Joshua remained in a very serious condition. He was receiving absolute maximum life support including, inhaled nitric oxide, inotropes, adrenaline, dopamine and dobutamine. Joshua had low blood pressure and was acidotic.
We were advised that his best chance of survival was extra corporeal membranous oxygenation (ECMO). This is a technique that provides temporary heart and lung support.
After some deep consideration, we signed the forms giving permission for Joshua to be put on ECMO. This was a hard choice as ECMO has numerous risks. However, we knew this was Joshua’s best chance and we felt we had no alternative.
Joshua was transferred to Newcastle for ECMO by helicopter and we followed by car.
When we arrived at Newcastle, Joshua had been successfully transferred to ECMO.
We were told upon arrival that he had an 80-90% chance of survival.
I will never forget seeing Joshua on ECMO for the first time.
Joshua was very brave, he often opened his eyes when he heard our voices. He could squeeze a finger when placed in his hand. Not being able to pick him up and cuddle him was heartbreaking. Joshua was being given Hoa’s breast milk and it helped us to know we were doing something for him.
Up until 3 rd November, Joshua was doing very well on ECMO. All the feedback we had been given was that Joshua’s lungs were recovering and that his prognosis was good.
We were told that he was likely to have neurological problems and that these could be anywhere from mild to severe. We came to terms with this and just wanted to take our boy home.
On the night of 3 rd November (unknown to us), the staff attempted to wean Joshua from ECMO.
At the latter stages of weaning, Joshua began to bleed from his left lung. This was a disastrous development as when a child is on ECMO, heptin is used to stop blood clots outside the body. This makes any bleeding very serious.
Over the next 2 days, Joshua’s condition deteriorated. Joshua’s struggle for life became ever more desperate.
On the 5 th November 2008, around midday we were told that Joshua’s bleeding was too severe and it was time to turn off the ECMO machine.
In tears we agreed to let Joshua go. I begged the doctor to ensure that Joshua went without pain. For the next 15 minutes I sat embracing Hoa. We knew our beautiful boy was passing away. A short while later his death was confirmed. Joshua had bled to death.
We sat numb for a while, the staff were wonderful and gave us lots of support.
They dressed Joshua is his baby clothes and we got to say our final goodbyes.
No words can ever describe the pain of seeing and holding our dead baby boy.
The day Joshua died, we stayed overnight in a hotel near the hospital with my parents.
The day after, we drove home. Emily travelled with my Mum and Dad, Hoa travelled with me.
On several occasions, I had to stop the car because my wife had tried to open the door to jump out.
The Cover up starts
Around a month after Joshua’s death, we were informed that the key record of Joshua’s care, the yellow “observation chart”, which turned out to be the only record of Joshua’s monitoring prior to his collapse had been “lost”.
Despite “extensive” searches, it has never been found.
On 8 th February 2009, during a meeting with the CEO of the trust, we were told:
“ Mr Halsall replied that he in no way wished to trivialise the fact that the chart was missing but that he felt that, only if the staff statements had said something different to the chronology provided by the family, would it have created difficulties in the investigation….”
“ Mr Halsall apologised that the chart remained missing but stressed that he believed, in view of the family and staff reporting the same sequence of events , that it had not fundamentally affected the outcome of the investigation ”
Refusal to share Information
Given the loss of Joshua critical observation chart, and the general lack of other records documenting Joshua’s care. We felt it was important to understand what the staff had reported had happened to Joshua. We repeatedly asked the CEO to allow us to see copies of the staff statements.
On the 24th of April 2009, Tony Halsall wrote to us as follows:
“ I write in reference to your request for copies of the statements made by staff in relation to Joshua’s care. These statements are not available under the Freedom of Information Act and at this stage I do not intend to copy them to you.”
After a long fight, we eventually obtained the staff statements under DPA. We found the following had been misreported by staff:
1. Hoa’s Illness and how we had spoken to staff in detail about this.
2. Joshua’s lowest temperatures and signs infection prior to his collapse.
1. Hoa’s Illness
Only a brief mention of “ a slight headache ” is made in the statements. No other mention of the illness is made at all.
This is despite the detailed conversations we had with staff regarding my wife’s illness and the advice we were given that it was “probably a virus” and “a lot was going around”.
2. Joshua’s lowest temperatures
The LSA report states “.... information suggested that the fluctuations in Joshua’s temperature were between 36.4°C and 36.8°C .” It goes on to say that “Further investigation by the Head of Midwifery revealed that this degree of fluctuation in a newborn’s temperature may not have prompted a request for a paediatric review by other midwives in the service either, but may have been seen as the normal variation in temperature of a newborn that can occur in response to the environment .”
This is despite the fact that my wife clearly recalls reading two of the temperatures on the “missing” observation chart as being 35.8 °C and 36.1 °C . The temperatures the staff have claimed to recall just happen to be above the threshold for which medical intervention should have been obtained.
Parliamentary and Health Service Ombudsman (PSHO)
Following the publication of the trust’s report, we referred Joshua’s death to the PSHO . After nearly one year of considering our case, the PSHO refused to investigate our concerns. Amongst the reasons given were:
“ As you know, despite thorough searches, the records for the first 24 hours of Joshua’s life are still missing. The staff involved had been interviewed on more than one occasion. It is unlikely that they would now change their accounts of the events and for this reason, in the absence of records, a further investigation is not likely to reach a firm finding of what took place and why”
The PSHO also pointed to the Care Quality Commission (CQC) as being the organisation with responsibility to ensure standards at FGH were maintained.
Care Quality Commission (CQC)
In December 2009, Alan Jefferson (then North West Regional Director), wrote a very powerful letter to me. This included the statement ‘ We believe that if future tragedies are to be avoided, the trust needs to be able to evidence a much more integrated approach to care’.
Mr Jefferson’s letter concluded with the following. ‘ I am conscious of the current press publicity surrounding the death of a child in Milton Keynes and imagine that this will resonate with your experience and cause you further distress. The reporting has referred to direct investigations undertaken by our predecessor body the Healthcare Commission. As you are probably aware, the Healthcare Commission had powers to investigate complaints about the NHS that were not transferred to the Care Quality Commission. This explains why the two matters were dealt with different.’
This is a clear indication that the CQC would have investigated Joshua’s death had the regulatory framework not been changed.
Furness General Hospital – Maternity Services Update
In March 2010, an in depth, independent review of maternity services across the trust was published (known as the “Fielding” report). Amongst the findings of the review were :
The unit in Barrow in Furness (FGH) has been the site of the cluster of a number of adverse outcomes…………”
“ It was clear from most of our interviews that team working is dysfunctional in some parts of the maternity services….”
“ The legacy of the Serious Untoward Incidents has not helped here – the review team heard that relationships between obstetricians and paediatricians at FGH is improving but there is still much more that needs to be done”.
“ The review team felt that multidisciplinary ward rounds do not take place on the labour ward at FGH”.
"The hospital facilities are not entirely fit for purpose, particularly with respect to the labour ward environment and the distance of theatres and compare unfavourably with others in the trust".
Furness General Hospital – Maternity Services Update cont….
There is also a history of poor relationships between midwifes and neonatal staff although this was felt to be improving…”
“ It became apparent during the course of the interviews that there is little understanding of the concept of clinical governance”.
“ Training opportunities for midwifes are seen to be somewhat problematic with training budgets cut”.
“ It was apparent during most of the interviews that there is a lack of common understanding of the role of the Supervisor at all levels of the organisation. This matter has a troubled history in the events which followed the SUI of Baby T (Joshua) but is not entirely related to this incident.
“ It was evident that the relationship between midwifes and senior managers had been damaged by the fallout from the incident but that this was gradually improving with some trust being restored”
“ The trust has found it increasingly difficult to attract and appoint high calibre staff of all types. The staff working at FGH have found conditions to be challenging in the last few years”.
“ For these reasons the morale of the staff in the maternity service has been badly affected. Relations between different categories of the staff and between management have suffered within an atmosphere which at times may have embodied a “blame culture”.
Fielding Report Secrecy
It has since been established that:
The Fielding report was kept secret from the CQC during their critical assessment of maternity services at FGH in Summer 2010. Even in March 2011, the trust had not provided the CQC with a copy.
The HSE confirmed in June 2011, that despite the work they are doing with the trust, the Fielding report has never been shared with them.
The CQC approved maternity services at FGH (which in turn led to Foundation trust status approval), without any knowledge of the significant concerns raised by Dame Fielding in her comprehensive review.
In June 2011, an inquest was finally held into the circumstances of Joshua’s death. 10 failures were identified.
The Coroner accepted the low temperatures my wife recalled were truthful.
The Coroner accepted that we had discussed Hoa’s illness with staff prior to the birth.
Failure to listen to and understand the family’s concerns;
Failure to record fully or at all many of the factors which, taken together, might have led to a greater degree of suspicion or a referral to a paediatrician; Failure by some staff still to recognise that the standard of record keeping was unacceptable;
Failure to understand a basic medical fact that a low temperature or a failure to maintain a temperature could be a sign of infection in a neonate;
Failure to monitor the signs of infection in Joshua;
Absence of continuity of care before and during the birth;
The treatment of the protocol on Prolonged Rupture of the Membranes as a rigid formula and not as a tool to make a considered diagnosis and (if necessary) to get a doctor to attend;
Mrs Titcombe and Joshua were treated as unrelated individuals. No thought was given to how, if something was affecting Hoa, it might also affect Joshua. Failure to think of them laterally and holistically as a mother and baby.
Failure by all staff to acknowledge that the midwives were working as a separate team and that there was no integration between the midwifery and paediatric teams;
Failure to identify that the unit was short staffed on that day;
Inadequate, or no, training for midwives on the post-natal ward to carry out the observations that the SCBU nurses had done.
Missing Medical Records
The Coroner expressed his serious concerns that Joshua’s observation chart may have been “ deliberately destroyed ”
He said there was a “ very worrying mark of suspicion ” hanging over the maternity unit at FGH
The Coroners accused the midwives who gave evidence of getting together to collaborate their evidence.
The Coroner did not accept that all the midwives who gave evidence had no idea that low temperature in a neonate could be an indication of infection… he said “ it was basic medical knowledge ” and that the midwives claims were “ inconceivable ”.
‘ Every member of staff has taken this as a learning experience and been totally open, honest and fully co-operative with the investigation’ ‘ We have shared all of our information and findings with every agency in the spirit of openness and honesty in which we pride ourselves and operate as an organisation.’ – Press statement from Tony Halsall, the North West Evening Mail – 15th January 2010.
“ Having discussed this with Dr Paul Gibson, his estimate of Joshua’s likelihood of survival if antibiotics were started at the same time as Hoa would be around 90%” The situation at FGH maternity unit that led to Joshua’s death must never be allowed to happen again.
Is it too late……?
The Coroner has now written to the trust under rule 43 about a number of current issues.
The Police are investigating the circumstances of Joshua’s death in light of the Coroners findings.
The CQC are conducting a “significant” response review since recently receiving the Fielding report
But have other preventable deaths occurred at FGH as a result of ongoing issues which should surely have been sorted out much, much sooner?