A recent Professional Standards Authority report has just been published regarding avoidable deaths at Furness General Hospital. One of many terrible outcomes of the series of maternity deaths, both babies and mothers, at the hospital, is the way that grieving families were left without vital information about why their loved ones died.
The medical negligence team has written before about the absolute necessity of hospitals to be transparent with people traumatised by death to help them stand any chance of moving on with their lives. We've also written about hospital trusts that refuse to acknowledge the mistakes behind tragedies, compounding the ordeal for those affected.
Between 2004 and 2012, it has been reported that up to 19 babies and mothers died at Furness General Hospital because of mistakes by staff on the maternity unit. An inquiry into those deaths concluded that 13 of the women and babies would have lived had they received better care.
The Nursing and Midwifery Council (NMC) has been criticised for its handling of this catastrophic situation, including concerns that it failed to address ongoing problems in the maternity unit for more than two years, despite warnings from the police.
The report into the deaths commissioned by health secretary Jeremy Hunt also highlighted the 'culture of denial' that meant responses to families were 'defensive', 'legalistic' and 'grossly misleading'.
One of the fathers whose baby died published a brutally honest account of the treatment he received, which certainly makes uncomfortable reading.
James Titcombe's baby son Joshua died at the hospital in 2008 when midwives failed to spot that he had an infection. But as Mr Titcombe tried to find answers as to what exactly had happened, he came up against 'years of dishonesty, obfuscation and, at times, outright hostility'.
Mr Titcombe writes in the Guardian: "Critical records of Joshua’s care went missing, statements from staff were dishonest, investigations were superficial, the organisations that should have been taking action to ensure the maternity services at Morecambe Bay [the Trust in charge of Furness General Hospital] were safe instead acted to reassure each other that everything was OK."
The author of the report, Dr Bill Kirkup, said that the Trust had had the opportunity to identify that things were going very wrong at the hospital as far back as 2004 when a baby girl died, but the death was 'effectively covered up'. The family was not told the truth, unsafe care at the maternity unit continued and 11 more babies and one mother died unavoidably between 2004 and 2013.
Clearly, there are multiple, extremely serious issues here that the report will continue to expose. But at the root of the problem is the initial refusal to investigate properly when something goes wrong. That lack of transparency has to be blamed on a culture of refusal to respect those affected, instead focusing on protecting the reputation of individuals and the organisations involved. This flies in the face of the duty of candour that healthcare organisations must adhere to.
While Jeremy Hunt promises more funding for NHS maternity units and rightly focuses on better care, this must go hand-in-hand with an overhaul of the entrenched culture and attitude that allowed the gross misconduct at Furness General to continue unchecked for so many years.
I continue to see too many cases where parents have to fight for months, even years to obtain information about their baby's death or catastrophic injuries, including cerebral palsy, where it is clear that things have gone wrong.
A recent example is where a family was told that the circumstances behind their baby's significant birth injury were being investigated. Despite promises from the hospital of regular updates, which they repeatedly asked for, they were not contacted regarding the outcome or provided with a copy of the hospital report until I was instructed some months later and could begin to assert formal pressure on the hospital trust.