Key mistakes by a law firm undermined an investigation into baby deaths at a hospital, a damning new report has concluded. National firm Capsticks was today named as having failed to provide the regulator, the Nursing & Midwifery Council, with a vital document prepared by the father of one of the dead children.
The NMC today apologised to the father, James Titcombe, for errors in its investigation and the ‘unacceptable’ way in which he and his family were treated.
Following a number of concerns being raised about deaths at Furness General Hospital, the Morecambe Bay Investigation (also known as the Kirkup review) was established in September 2013.
Amongst other issues, the report identified problems with the handling of a chronology of events provided by Titcombe, whose son Joshua had died at the hospital in 2008. Last year, the NMC commissioned independent investigator Verita to review the way it handled the chronology.
Today’s report said Capsticks, instructed to handle NMC investigations until 2010, had failed to include the document in the original case file, with the regulator failing to notice it was not included in a statement on the case. The mislaying of the chronology was ‘clearly unsatisfactory’, said the report, and Capsticks should have allowed Titcombe to review his statement earlier and ensured the NWC had the correct documentation.
Titcombe had first raised issues about the performance of midwives with the NMC in February 2009 and the cases of four midwives were passed to Capsticks in September 2009, Mr Titcombe made a statement to the firm a month later.
At the time, the firm sent early versions of a case file to the NMC before it was complete, with updates inserted later. The aim was to speed up the process.
The report found this procedure, which is no longer followed, was ‘unusual’ and created the risk there would be no single agreed version of the file.
Titcombe asked Capsticks several times for updates on the case and expressed frustration at the delay and concern that statements taken from the family had not been issued.
The chronology was not appended to the original version of Titcombe’s statement, which was sent to the NMC. It is not believed the NMC ever received a copy of the chronology prior to him emailing it in 2016.
The report said: ‘Ensuring proper filing and recording of documents is an important part of the role of external solicitors and the failure to keep track of documents in this case is disappointing.’
The Capsticks report was sent to the NMC in May 2010 and recommended there was no case to answer against the midwives. Today’s report finds that Capsticks’ work was completed ‘in a hurry’ as the paralegal working on the case was about to leave the firm. Having spent six months developing the witness statement, final additions were made by Mr Titcombe and sent in the final report without a further period of reflection and checking. This aspect of Capsticks’ process was deemed ‘unsatisfactory’.
Today’s review concludes that the NMC’s processes for external lawyers have changed and documents are now handled electronically to identify omissions earlier.
Andrea Sutcliffe, NMC chief executive and registrar, said today the regulator had at the time a culture that ‘prioritised process over people’ and when concerns were raised ‘we acted defensively and dismissed those concerns’.
The Gazette has approached Capsticks for comment.