Sunday, April 19, 2009

'Hospital blunders meant my baby bled to death': Father's grief as NHS staff ignore plea to treat nine-day-old son

And the hospital is covering up -- has already "lost" relevant records that might identify the irresponsible staff. Don't you just LOVE that socialized medicine?

A heartbroken father told yesterday how his newborn son bled to death in hospital after a series of blunders by NHS staff. Joshua Titcombe was nine days old when he died from a common infection picked up from his mother which could have been cured with antibiotics. James Titcombe said he and his wife Hoa had urged staff at Furness General Hospital, in Cumbria, to treat Joshua with antibiotics but they were told he seemed well and did not even need to see a doctor. Mr Titcombe, a 31-year-old engineer, said they were told a paediatrician was 'too busy' to deal with them.

But the baby later had to be airlifted to two other hospitals where he eventually bled to death after the infection damaged his lungs, causing a massive haemorrhage. Mrs Titcombe, 32, a charity worker, went to hospital after her waters broke three weeks prematurely following a spell of feeling unwell. Hours after Joshua was born, Mrs Titcombe collapsed and was given antibiotics for an infection.

But while Joshua's temperature fell, his family's pleas for him to be examined by a doctor were ignored. Mr Titcombe said: 'My concern for Joshua was immense. I repeatedly asked if he needed antibiotics and was very surprised to be told he didn't. 'This seemed counter-intuitive to me but I had no choice but to trust what I was told.' It became clear the next day that Joshua was unwell - and at this point he was given antibiotics before being airlifted to Manchester and then Newcastle.

Mr Titcombe said: 'The day after he was born, I had come to take my wife and baby home when they found him not breathing well. It was a horrific shock. 'They told us he had a problem with his heart, then with his oesophagus. All the time I just suspected he had the same infection as his mother.'

In Newcastle consultants said his problem was an untreated pneumococcus infection - the same condition as his mother. Joshua died a week later in October 2008 on a life-support machine.

His parents, who have a four-year-old daughter, said they are also upset that the medical records of Joshua's stay in Furness General appear to have gone missing. They have asked the Health Service Ombudsman to investigate. Mr Titcombe said: 'His observation chart, which I saw when we were in the hospital, has been lost and we have had no explanation as to how this could have happened. Anything which could lead to the identification of individuals who failed him has mysteriously disappeared. The records would have answered a lot of our questions.' He added: 'The failures that led to Joshua's death must not be swept under the carpet.

Tony Halsall, chief executive of The University Hospitals of Morecambe Bay NHS Trust, told the couple in a letter: 'The care received by Joshua was not acceptable. We let him down and as a direct consequence he lost his fight for life. I would like to offer my heartfelt apologies.' He added yesterday: 'We are doing everything we can to prevent this from ever happening again.' [Bullsh*t, Bullsh*t, Bullsh*t]


Desperate attempt to fix the unfixable

The NHS has recruited two captains of industry, a former director-general of the BBC, a vice-admiral and an author and psychologist in an effort to improve leadership in the health service, The Times has learnt.

Greg Dyke, who ran the BBC for four years, and Sir Stuart Hampson, the former chairman of John Lewis, are among a group of health service “outsiders” being brought in to give insights on raising standards in very large organisations. Lessons on discipline and motivation are likely to come from Vice-Admiral Sir Adrian Johns, a former Second Sea Lord and Commander-in-Chief of Naval Home Command, who commanded HMS Ocean in the Iraq war.

The move, which mirrors Gordon Brown’s attempt to create a government of all the talents, will also involve contributions from Daniel Goleman, author of the bestselling book Emotional Intelligence, and Gary Kaplan, a doctor and chief executive of a network of private clinics in the US.

The appointment of the five men as patrons of a new National Leadership Council will be announced this morning, with the council’s first meeting scheduled for next week. The patrons will receive set fees of £144.62 a meeting. The council has been given the task of driving up standards in the NHS by showing what world-class leadership looks like and trying to develop such skills at every level.

It will also have 25 core members, all with longstanding NHS experience, who will focus on championing five key areas: clinical leadership, encouraging more doctors and nurses to take on executive roles, improving the standard of NHS trust boards, getting the highest quality applicants for all senior jobs, improving “inclusion” to ensure that leaders reflect the community they serve, and identifying the next generation of leaders. Each issue will have a lead member, who will be expected to provide two days a week and receive pro rata payment in line with their current NHS salaries.

A faculty of fellows is also being created to support the council, which will meet six times in its first year, with patrons attending when called upon.

The NHS, which employs 1.4 million people, has faced repeated criticism over the years for failing to make the most of its talent pool and resources. The latest warning came last month when the health regulator identified a failure of leadership at Mid-Staffordshire NHS Foundation Trust as key to safety issues that may have contributed to more than 400 deaths at its hospitals.

David Nicholson, the NHS chief executive, who will be chairman of the new council, said that the overhaul was essential to ensuring that the highest standards were achieved. “Leadership is the vital ingredient that can make all the difference to the quality of care that our patients experience,” he said. “Great leadership, which focuses on improving services for patients, will help transform the NHS.” “We want to improve the overall quality of our leaders, equipping them with the skills to make our vision a reality.”

Mr Nicholson said that the council was being created as part of a commitment set out in the Government’s strategy for the future of the NHS, High Quality Care for All, and after extensive consultation with the NHS and leadership experts.

Mr Dyke said yesterday that his new appointment brought a range of challenges. “This is an exciting initiative at a critical moment. Leadership is at the heart of the NHS,” he said. “I look forward to making a contribution and ensuring that we deliver results that inspire confidence from all within and outside the NHS.”

Mr Goleman, an American psychologist and journalist, developed the argument that “non-cognitive skills” can matter as much as IQ for workplace success, which became the subject of an international bestselling book. Sir Adrian Johns, who trained as a helicopter pilot, served in the Royal Navy for more than 30 years. Dr Kaplan is chief executive of Virginia Mason Medical Centre, a private, not-for-profit organisation offering a network of primary and specialtyspecialist care clinics in the United States.

The NLC will work in partnership with the recently announced National Quality Board (NQB).


Australian public hospitals that can't even get simple basics right

If putting the correct ID armband on a baby is too hard for them, what does that say about more complex things that they do?

NEWBORN babies in Queensland are being regularly mixed up and wrongly tagged, with some errors taking days to fix. In one case, a mother had to have HIV and other tests after being given the wrong baby to breastfeed. The blunders have more than doubled in three years, with staff blaming distractions, poor communication and increasing workloads.

Newborns are supposed to have three tags for accurate identification but documents obtained by The Courier-Mail reveal there were 57 bungled identifications last year. Parents or Queensland Health staff found almost half of them had no tags or all three tags with the wrong name, mother's name or patient number.

In the breastfeeding case at the Royal Brisbane and Women's Hospital last October, a mother had to have hepatitis and HIV tests after being given the wrong baby. "(The) wrong baby was taken to the mother," the report obtained under Freedom of Information laws found. "Baby's arm bands were not checked. Baby was fed by wrong mother before mistake was discovered."

Another case took four days to solve after a baby was transferred from Townsville Hospital to Cairns Hospital. The baby arrived in Cairns with no tags and weighing 160g less than when it left after staff in Townsville failed to conduct routine ID checks for three days before the transfer. "The baby has been identified as certain as possible at this point in time," staff said on October 2, 2006, after checking every baby at both hospitals. The identity was finally confirmed on October 5.

Queensland Health child safety director Corelle Davies yesterday defended the increase in cases, saying the bungles were always rectified before the babies went home. "Accurate patient identification is fundamental to the provision of safe health care and is taken seriously by staff in all Queensland Health facilities," Ms Davies said. "Staff are trained and work hard to ensure babies have correct identification. Very stringent guidelines are in place to ensure baby name tags are checked by both the mother and staff."

However, Australian College of Midwives state executive officer Jenny Gamble said the errors were a result of an understaffed system requiring urgent restructure. "Every man and his dog is involved - midwives, nurses, different sorts of allied health staff -- but no one is there all the time like two or three midwives could be," she said. "We need it to be much more personal."

The FOI documents show the number of cases reported jumped from 27 in 2006 to 55 in 2007 and 57 last year. In a typical case at Toowoomba Base Hospital last October, a staff member bathing a newborn discovered the baby had no identification. "When I undressed the baby to do a demonstration bath, I discovered that the baby had no identification bands and no identification tape on her back," the staffer said in a report.


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