My life changed forever on 5th November 2008 when my baby son Joshua died. Joshua was born just 9 days earlier – a perfect beautiful baby boy. Shortly after his birth, my wife collapsed with sepsis and was quickly given fluids and antibiotics. Over the next few hours, my wife recovered. We were both concerned for Joshua, but when we asked the midwives whether he might be at any risk, we were simply reassured that he was ‘absolutely fine’. We were told that staff would keep a very close eye on him and that we shouldn’t worry.
Over the next 24 hours, Joshua in fact had many signs of developing sepsis – He was lethargic, reluctant to feed, breathing quickly and heavily and his temperature was low and fluctuating, prompting staff to put him repeatedly into some form of heated cot. My wife and I raised concerns, but each time we did we were reassured that Joshua was fine.
The next day, in the early morning, my wife found Joshua collapsed in his cot. He was blue and struggling to breath. He was rushed to the special care baby unit and put on a ventilator. Initially we were told that he may have collapsed due to heart defect, but it was soon established that he had overwhelming of sepsis – caused by the same infection that led to my wife’s collapse 24 hours earlier.
From this point onwards, Joshua fought for his life in 2 specialist hospitals, which provided the very best care possible. However, the damage the infection caused to his lungs was simply too great and Joshua passed away as a consequence of uncontrollable bleeding in his left lung.
In the weeks and months that followed, we pushed the hospital where Joshua was born for answers as to what happen and why. We wanted to know why Joshua’s hadn’t been reviewed by a pediatrician earlier and why he hadn’t been given antibiotics after his birth.
Sadly, rather than responding to what happened openly and honestly, the trust and staff involved in Joshua’s care acted to conceal the truth. Crucial records of Joshua’s observations were ‘lost’. Subsequent investigations carried out by the hospital claimed that Joshua’s observations were all within a ‘normal’ range and that even if he had been given antibiotics earlier, there was no way of knowing whether or not this would have altered the outcome for him.
It took many years to eventually uncover the full truth about why Joshua died. In March 2015, an independent investigation into maternity services at the trust was published. This report found that a ‘lethal mix’ of failures had led to the preventable deaths of 11 babies and 1 mother. Joshua’s death was entirely avoidable and was part of a much wider pattern of systemic failures that had been ongoing for years before he died.
The report made a number of significant recommendations for change and led to a new national drive in England to reduce avoidable harm and deaths in maternity services by 50% by 2025. The report also led to the establishment of a new national body that now investigates unexpected outcomes in maternity services like Joshua’s death – with a focus on learning to prevent future harm rather than individual blame.
Nothing can ever change what happened to Joshua, but I hope that part of his legacy will have been helping prevent other families going through the heartache and grief we experienced.
