Latest News About England: NHS ombudsman delivers scathing verdict on Furness hospital trust

Dame Julie Mellor says trust's lack of honesty hurt bereaved family of Joshua Titcombe after baby's death aged nine days

An NHS trust's lack of honesty caused "unnecessary pain and further distress" to a family who had already suffered from the tragic and avoidable death of a baby boy, the health service ombudsman has said in the latest scathing verdict on the defensive culture within the health service.

Change was needed "from the ward to the board" said Dame Julie Mellor as she upheld three of four complaints made by relatives of Joshua Titcombe against University of Morecambe Bay NHS foundation trust.

Mellor had already upheld a complaint from James Titcombe, Joshua's father, against the NHS's now-defunct strategic health authority in north-west England, over how it investigated events at the trust.

Cumbria police are still investigating Joshua's death. He was born at Furness general hospital, part of the trust, in October 2008 but was transferred to hospitals in Manchester and then Newcastle where he died from pneumococcal septicaemia, just nine days old. The trust later confirmed that Joshua would have had an excellent chance of survival if opportunities to diagnose and treat his infection had not been missed.

In remarks that echoed the fallout from Sir Robert Francis's report on the scandal at Stafford hospital last year and other incidents, the ombudsman said that the relationship between the Titcombe family, whose identities are anonymised in the report, and the Morecambe Bay trust was "a further sad example" of the need for cultural change.

"Hospitals and other healthcare 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," said Mellor.

"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."

Mellor said hospital boards should "reward staff who seek and respond well to concerns and complaints, including acknowledging mistakes."

She also apologised for a decision in 2010 by her predecessor, Ann Abraham, not to investigate a complaint from Titcombe. "We recognise that had we investigated, the family might have had answers to some of their questions regarding what happened to their baby sooner than they did. We are sorry for the impact this has had on the father and the baby."

Mellor said the trust had been guilty of maladministration in the way it investigated events surrounding Joshua's death and its failure to explain two inappropriate email exchanges between staff at the trust. James Titcombe had suffered injustice and she could understand his loss of all confidence that the trust would learn from his son's death.

The subject heading of one email between staff, discussing an investigation into midwives' conduct and practice before Joshua's death by the Nursing and Midwifery Council, the professional regulator, was "NMC shit".

The trust did not write and apologise to James Titcombe until nearly 17 months after the incident despite claiming in a press release in 2011 that it had apologised at the time, said Mellor.

In another exchange of emails, this time between the trust's customer care manager and the head of midwifery, the head of midwifery replied to a message that there was some "good news" about James Titcombe's complaint over his son's death. She wrote asking whether Titcombe had "moved to Thailand? What is the good news?" Joshua's mother is Vietnamese.

Mellor said she could not go as far as to say the head of midwifery had shown racial or ethnic prejudice, but her email "fell so far below the standards of respect and courtesy to be expected in these circumstances that it amounted to maladministration".

The ombudsman did not uphold Titcombe's complaint, supported by his father, that midwives had colluded before the inquest.

Titcombe said Mellor had made strong recommendations for change which the family supported, "in particular the need for honestly and robust incident investigation following avoidable harm or death in the NHS" employing particular techniques for which staff were properly trained.

"This is a hugely important recommendation and one which if the NHS implements, will make a significant difference to patient safety," said Titcombe.

"We acknowledge and welcome the ombudsman's apology for the original decision not to investigate Joshua's case. However, significant question marks about the circumstances of how that decision was made remain. Too many people have been failed by the ombudsman's service in the past and this must not be allowed to happen again.

"My family and I wish to make it clear that we do not accept the ombudsman's report in relation to how staff prepared for Joshua's inquest," he added.

"Joshua's death has had an unbearable impact on our family. We miss him every day and continue to be haunted by the trauma of his short life and his horrific preventable death. The last five years have been made so much worse because of the way the trust and other organisations responded to his loss. "

The south and east Cumbria coroner, Ian Smith, criticised failings at Furness hospital at Joshua's inquest in 2011 and an independent inquiry chaired by Bill Kirkup, set up by Jeremy Hunt, is still investigating a series of deaths of mothers and newborn babies at the hospital between 2004 and 2013.

Alleged cover-ups by the Care Quality Commission watchdog of what had happened at the trust led to Hunt, the health secretary, saying such flaws undermined the "amazing job" done day in, day out by most NHS staff.

James Meikle

Haroon Siddique