Titcombe investigation finds 'basic failings' in care
An investigation into the death of a baby which triggered the discovery of a major scandal in neonatal care at an NHS trust found "many missed opportunities" and basic failings in his care.
Joshua Titcombe died after suffering pneumococcal septicaemia and a lung haemorrhage on November 5 2008, nine days after he was born at Furness General Hospital in Cumbria.
An inquest in 2011 heard midwives repeatedly missed chances to spot and treat a serious infection which led to his death while an inquiry last year found a "lethal mix" of failures at the University Hospitals of Morecambe Bay NHS Foundation Trust led to the unnecessary deaths of 11 babies and one mother between 2004 and 2013.
Midwife Lindsey Biggs was struck off last month for failing in her duty of care to Joshua, while another midwife, Holly Parkinson, was suspended for nine months.
A new investigation was commissioned by the trust and carried out by experts from Central Manchester Foundation Trust to tackle unanswered questions and ensure lessons are learned.
Among 22 key findings and 18 recommendations it highlighted a host of "missed opportunities" in the care of Joshua and his mother Hoa which would have "probably altered the outcome".
The report found that if thorough observations been carried out and a consultant paediatrician been notified Joshua would have been given antibiotics and admitted to intensive care, meaning he "would have almost certainly survived".
It was "highly improbable that there were normal neonatal observations" on the morning Joshua was taken ill, and the suggestion from a midwife that all his observations were normal is "not a credible version of events". Records from the time have also been lost.
The standard of care Mrs Titcombe received following her own collapse was "not safe", and she only got better because of the "fortuitous use of a broad spectrum antibiotic" rather than proper and careful assessment.
The report concluded:
The trust also set up a meeting between Joshua's father James Titcombe and one of the midwives implicated in his son's death.
Mr Titcombe told the Health Service Journal:
Following the report's findings, Mr and Mrs Titcombe said:
Jackie Daniel, the trust's chief executive, said the full investigation into the whole case should have been carried out much earlier.
She said: