Lack of openness and honesty at University Hospitals of Morecambe Bay NHS Trust caused unnecessary distress and pain to a family already suffering from the “tragic and avoidable death” of their baby, said the Parliamentary and Health Service Ombudsman today, Thursday.
The Ombudsman Service investigated five complaints about UHMBT which relate to the way in which it handled the Titcombe family’s complaints concerning the death of their baby, Joshua, at Furness General Hospital, in 2008.
The complaints it investigated focused on inappropriate email exchanges between staff at the hospital and the complainant, the quality of the investigations the Trust carried out into the death of the baby and an allegation of collusion amongst midwives in preparation for an inquest.
The trust apologised for its “unacceptable” actions and said it acknowledges and fully accepts the findings.
The report said: “We upheld the two complaints about inappropriate email exchanges between the involving members of staff at the Trust.
“We upheld the complaint about the adequacy of the investigations the Trust carried out, following the death of the baby.
“We did not uphold the complaint concerning the allegation of collusion amongst midwives.
“We also investigated and upheld a complaint from the baby’s father about North West Strategic Health Authority.
“This concerned how they investigated events at the Trust.”
Jackie Daniel, Chief Executive, University Hospitals of Morecambe Bay NHS Foundation Trust, said: “There is no doubt that the Trust has badly let down the family following the tragic death of their baby in 2008.
“Clearly some of the actions highlighted by the Ombudsman have caused further unnecessary distress and pain. This is completely unacceptable and we are truly sorry for this.
“The Ombudsman has upheld three out of four complaints made against the Trust and the Board will ensure that the recommendations from these are acted upon as
“Since these incidents took place we have taken steps to improve the areas highlighted in the report. The way that incidents and complaints are handled by the Trust has changed and new governance arrangements have been put in place, so that all moderate and severe incidents and subsequent investigations and action
plans are now reviewed weekly by the Executive Chief Nurse, Medical Director and senior clinicians. This helps the Trust to identify that investigations have been thorough, appropriate guidelines are followed and when further action is required.
“We expect staff to always communicate in ways that are appropriate and sensitive to the needs of patients. We have introduced regular training seminars for staff about the appropriate use of emails and other communications at work. The Trust will respond to the recommendations in relation to this accordingly.
“The Trust has fully cooperated with the Ombudsman during this process. We acknowledge that there may be aspects from these reports that the on-going Police
investigation and the independent investigation into maternity and neonatal services may wish to consider. We will continue to fully support and cooperate with both of these investigations.”
Julie Mellor, Parliamentary and Health Service Ombudsman said: “We are publishing these reports as they highlight the need for more openness and transparency in the way hospitals and the wider health and social care system deal with complaints.
“Hospitals and other health care providers have a duty to patients and their families to investigate their concerns properly.
“In these cases the Trust failed to be open and honest about what went wrong and this caused the complainant and his family further unnecessary distress at a very difficult time.
“When serious untoward incidents happen there needs to be an independent investigation which looks at the root cause of the complaint and the role of human factors such as people and the organisation’s culture. We expect all service providers to adopt this approach to help them understand why mistakes happen and help improve services for everyone.
“Our recommendations underline how important it is that Trusts learn from complaints. This is what families want and deserve.”