It is very difficult to read unmoved the account, written by his father, of Joshua Titcombe’s nine days of life. It charts the excitement of James Titcombe and his wife Hoa about having a brother for their two daughters, through the difficult birth, their concerns about Joshua’s condition ignored by midwives and, finally, how they held their son after he had bled to death from a treatable infection.
“No words can ever describe the pain of seeing and holding our dead baby boy,” Mr Titcombe wrote. No family should have to watch their baby die, but their further agony of knowing that the death could have been avoided, that Joshua could today be a lively four-year-old boy, is unimaginable. Yet after all that, the Titcombe family were faced with secrecy, silence and cover-up from the hospital where their baby died and the very watchdog which should have blown the whistle on the tragedy.
Their pain is shared by the families of as many as 16 babies who died through lack of care at Morecambe Bay hospitals. There were, in total, 415 deaths in excess of the expected norm between 2010 and 2012 – the two years after the trust was approved by the Care Quality Commission. As Mr Titcombe writes on his blog, this is the equivalent of two fully loaded Boeing 737s crashing, with no survivors.
What happened at Morecambe Bay hospitals is a scandal. There will be a public inquiry into the deaths, but a report into the way the CQC failed to investigate the maternity unit, published yesterday, was damning. The CQC, which seemed to neither care nor have quality, ignored an internal review highlighting concerns about the maternity unit, giving it the all-clear in 2010, two years after Joshua’s death. CQC officials then attempted to cover up the failures.
There has now been a clear-out of senior managers at the CQC. The new chairman, David Prior, admits that the watchdog is not fit for purpose. So shouldn’t we all feel relieved that heads have rolled? Not quite. Yesterday’s report, by the consultants Grant Thornton, does not name individuals involved for fear it would breach the Data Protection Act.
So we do not know the identity of the senior manager who, when confronted with the watchdog’s failure to get a grip of Morecambe Bay, said: “Are you kidding me? This can never be in the public domain nor subject to a freedom of information request – read my lips.”
In a report that exposes a culture of secrecy in the NHS, it is unforgiveable that this official is not named. With anonymity, there can be no accountability. The Health Secretary, Jeremy Hunt, said yesterday that “the whole truth must come out, and individuals must be accountable for their actions”. There are exemptions to the Data Protection Act on the grounds of public safety. Mr Hunt must do everything in his power to make sure that this person is identified.
But what of the senior officials whose names we do know? They are no longer in their jobs, yet are they being held accountable?
Cynthia Bower, who was chief executive of the CQC at the time of the cover-up, resigned in February last year with a £1.35m pension. She was previously head of the West Midlands strategic health authority when another hospital scandal unfolded, at Mid-Staffordshire.
Dame Jo Williams resigned as chairman of the CQC last year after being accused of trying to brand Kay Sheldon, the board member who blew the whistle on the watchdog’s failures over Morecambe Bay, as mentally unstable. Tony Halsall stood down as chief executive of University Hospitals of Morecambe Bay last year, but with a payoff of £225,000.
Mike Farrar, who was chief executive of the North West Strategic Health Authority at the time of the scandal, is also accused by the Morecambe Bay families of failing to act. According to a letter written by Ms Bower in June 2009, the Strategic Health Authority had no concerns that there was a “common pattern” related to “serious untoward incidents” at the trust. Mr Farrar is now in one of the most senior positions in the NHS – the chief executive of the NHS Confederation.
There are, doubtless, many more NHS hospital scandals yet to emerge. It is often said that our NHS is the “best in the world”. When we have a child or other loved one who is made better by doctors and nurses at hospitals, we are so grateful that the affection pours forth. This gratitude for life-giving and life-saving has, understandably, upheld our faith in the NHS. But it is a faith that has left us blind, collectively, to when things go wrong. There have been too many hospital scandals where trusts promise to “learn the lessons”, only for another scandal to happen somewhere else.
The staff involved are sacked, resign, or are moved to another position. But too often the managers with whom the buck should stop never have to account for their actions. If senior managers believed that their job was on the line, maybe they would act quicker and work harder to stop a scandal.
Patients and their families need to have confidence in the NHS. Mr Titcombe said this week that the NHS is “rotten to the core”. This is a diagnosis that will be difficult to take for many people who are treated by the NHS every day. But perhaps he is right.