Morecambe Bay & the PHSO

1. Morecambe Bay & the PHSO

2. Introduction • In November 2008, baby Joshua Titcombe bled to death following a series of failures in maternity care at Furness General Hospital where he was born.

3. After Joshua’s death: Critical records of Joshua’s care ‘went missing’. The trust carried out an investigation which hid discrepancies between the staff accounts of what happened and those of Joshua’s parents. The trust investigation didn’t even involve interviews with staff The trust investigation failed to resolve key conflicts in what happened & left the Titcombe family with unanswered questions The Titcombe family referred their complaint to the PHSO

4. PHSO assessment of case • Over a period of several months, the PHSO case advisor (Harriet Clover) carried out an assessment of Joshua’s death and the trusts investigation. The case papers prepared in relation to Joshua’s case state: ‘Our Midwifery Adviser and our Neonatologist have confirmed that there appears to be a marked lack of Paediatric input into both Joshua’s care and into the Trust’s responses to his complaint’ Given the Trust’s apparent failure to handle Mr Titcombe’s complaint in a satisfactory manner, he has not been provided with a reasonable response to his concerns about events surrounding his son’s death.’ ‘I am concerned that this case may be demonstrative of a service failing with the Trust’. On 12th August 2009, the case advisor took Joshua’s case to the decision panel with a RECOMMENDATION THAT THE CASE SHOULD BE INVESTIGATED

5. What happened next? At a PHSO panel meeting on 12th – Ann Abraham said she would defer the decision pending discussions with the CQC. The note from the panel meeting states: 'We should talk to the family and explain the CQC and find out what they were willing to do.' The notes goes on '..she said she was not saying there isn't a glaring hole. We should wait. She said the decision should be deferred. Ann Abraham said that she was meeting with the Chief Executive of the CQC and will discuss how we secured the next best step. She said that we can't just leave it.'

6. Final Decision Ann Abraham finally wrote to the Titcombe family in February 2010 confirming a refusal to investigate the case. The Titcombe family asked for a review of the decision but the Ombudsman reviewer (Jonathon Tross) supported Ann Abraham’s decision not to investigate. The Titcombe family warned the PHSO that lives were at risk and begged Ann Abraham to change her mind but this was met with a firm refusal to discuss the case further.

7. The North West SHA In 2010, the Titcombe family also made a complaint to the Ombudsman about the actions of the NWSHA and the midwifery investigation carried out following Joshua’s death. Ann Abraham refused to investigate the families complaint. The Titcombe family appealed and asked for a review, but the reviewer (again Jonathon Tross) supported the Ombudsman’s decision.

8. Meanwhile at Morecambe Bay…. CQC registered the trust without conditions and later in 2010, Monitor granted the trust Foundation status. In July 2011, an inquest into Joshua’s death was eventually carried out (despite initial refusals from the Coroner). The inquest found significant failures in Joshua's care and the Coroner wrote a rule 43 letter. This prompted regulatory action and in February 2012, Monitor published a review of maternity services at the trust which found 119 serious risks to mothers and babies. From 2010-2013, we now know that 26 babies died following birth at Furness General Hospital, some have already been subject to inquest and found to have been preventable. What went wrong?

9. CQC In July 2013, the CQC published an external review into it’s actions at Morecambe Bay. The report found significant failures in CQC’s regulatory action and filled the front pages of the UK’s media for over a week. But what about the role of the PHSO? The Titcombe family took the decision to challenge Ann Abraham’s decision not to investigate the NWSHA via a Judicial Review (JR). This eventually led to an acknowledgement that Ann Abraham’s decision was ‘flawed’ and an investigation was eventually carried out which led to a report and national recommendations for change. In 2013, the PHSO also agreed to investigate how the trust responded to Joshua’s death, their subsequent report found the trust were repeatedly dishonest and failed to investigate or learn from Joshua’s death properly. But the new Ombudsman, Julie Mellor, has repeatedly refused to allow a review of why her predecessor failed to investigate Joshua’s death or respond to serious concerns about the decision raised by the family.

10. What we now know… In 2012, Mr Titcombe made a request for all information relating to Joshua’s case from the PHSO under the Data Protection Act (DPA). Within the information provided, was a memo from the former deputy Ombudsman Kathryn Hudson, to Ann Abraham. The memo was dated 10th September 2009 and stated “In your conversation with Cynthia Bower shortly before your leave, the suggestion arose that if we could assure Mr and Mrs Titcombe that as a result of their experiences CQC are now taking robust action to ensure improvements in the quality of maternity services in the Trust, you might decide not to investigate."

11. Not surprisingly, the Titcombe’s were concerned to learn that the Chief Executive of the CQC had held conversations with Ann Abraham where it was ‘suggested’ that the PHSO might not investigate their sons death. Mr Titcombe wrote to the Ombudsman asking for an explanation as was told: The PHSO were therefore denying that a conversation between Ann Abraham and Cynthia Bower took place as per Kathryn Hudson’s memo.

12. What we now know… When the Grant Thornton report was published in July 2013, it revealed new documents relating to the meeting with Ann Abraham and Cynthia Bower on 12th August. The Grant Thornton report refers to a ‘meeting plan’ produced by Ann Abraham before her meeting with Cynthia Bower. The Grant Thornton report (page 88 paragraph 3.230) states: "The CPHSO's [Ann Abraham's] meeting plan which she drew up only hours before her meeting with the CQC's then CEO [Cynthia Bower], appears to set out her intention to persuade CQC to launch an investigation at UHMB, something which she had also mentioned in the PHSO complaint assessment panel earlier that day."

13. Page 88 paragraph 3.231 of the Grant Thronton report states: "In light of the above it might reasonably be concluded that more likely than not that a discussion concerning which organisation was best suited to deal with the issues arising from the complaint occurred at that meeting." • Why wasn’t the meeting preparation note released to Mr Titcombe under his DPA request? • Why have the PHSO been dishonest with Mr Titcombe about these events?

14. Page 91 paragraph 3.246 of the Grant Thornton review concludes that the CQC had “on more than one occasion” assured the PHSO that "something was being done”. The report goes on to say that these assurances "appear to have persuaded PHSO not to investigate the complaint.". But what had the CQC agreed to do? What did Cynthia Bower agree with Ann Abraham at the meeting of 12th August to persuade her not to investigate Joshua’s death? If the PHSO had concerns that Joshua’s death represented a systemic failure and Ann Abraham felt there was a need for CQC to ‘launch an investigation’ what was agreed? There is no written agreement between Ann Abraham and Cynthia Bower and in fact, Ann Abraham and Cynthia Bower both deny discussing Joshua’s case in this way. Why does this matter?

15. It matters because lives were at risk at Morecambe Bay. Ann Abraham knew Joshua’s death hadn’t been investigated properly. The case advisor had recommended an investigation yet Abraham instead of investigating, had non documented meetings with the Chief Executive of the CQC. Ultimately, no action was taken at Morecambe Bay and the lives of Mothers and Babies remained at significant risk for years to come. http://www.hsj.co.uk/hsj-local/acute-trusts/university-hospitals-of-morecambe-bay-nhs-foundation-trust/mothers-and-babies-still-at-significant-risk-at-morecambe-bay/5041186.article

16. If Ann Abraham had refused to investigate the death of a child at a service which represented a risk to other mothers and babies because she was ‘reassured’ that another organisation would ‘do something’ – as a minimum, was it not a responsibility for Ann Abraham to properly agree and document what that agreed action was? CQC were holding their decision on the risk rating at Morecambe Bay on the Ombudsman’s decision on Joshua’s case. There was massive pressure from the trust, SHA, and Monitor to get the FT status back on track. Whose interests was Ann Abraham acting in when she refused to investigate the death of a baby boy that she knew had not properly been investigated by the trust?

17. How have the PHSO responded to concerns the raised? The Titcombe family have repeatedly written to Dame Julie to ask for an independent review of these circumstances. Dame Julie has repeatedly refused. Instead, the PHSO classified Mr Titcombe as a ‘risk’ to the reputation of the organisation and ensured all correspondence was passed through the lawyers.

18. The PHSO have sought legal advice in relation to Mr Titcombe’s concerns about how they handled Joshua’s case, which they are now refusing to release under ‘legal privilege’ Julie Mellor also initially refused to participate in the Kirkup investigation, arguing that the only way Mr Titcombe could seek a review of the what happened why was by Judicial Review.

19. Have PHSO learned? http://www.hsj.co.uk/news/ombudsman-absolutely-satisfied-with-morecambe-bay-response/5070768.article Mellor has said that she is ‘absolutely satisfied’ with the PHSO response to Morecambe Bay (see link above) – but have lessons been learned? The Tragic case of Sam Morrish reported in the Telegraph on 21st June 2014(see link above) clearly show not. http://www.telegraph.co.uk/health/nhs/10917119/NHS-Direct-failed-dying-three-year-old.html “The Patients Association, which has supported the Morrish family for the past three years, said: “As an organisation we have in the past recommended people to refer their complaints to the ombudsman in the confidence they would address those complaints properly, with full and honest answers. "But if the experience of the Morrish family is anything to go by it may well have failed hundreds of patients we have referred to them. The Ombudsman appears not to accountable to anybody and this dreadfully sad case shows that the ombudsman is not fit for purpose.”

20. Summary • The PHSO have repeatedly refused to allow a review of what happened and why • Answers provided so far have included outright dishonesty, including answers that conflict with the GT review • Key information which should have been released to the Titcombe family was not shared • The PHSO have done their utmost to avoid scrutiny of the issues • At least 26 babies have died following birth at Furness General Hospital following Ann Abrahams decision not to investigate.

21. How many other families have been failed in the same way? If the NHS complaints watchdog behave in this way – what example does this set for the wider complaints system? “To err is human, to cover up is unforgivable, and to fail to learn is inexcusable." Sir Liam Donaldson