• Quality improvement
• Quality improvement methodologies
• Process mapping

In 2008, I lost my baby son due to serious failures in his care at the hospital where he was born. Joshua’s mother collapsed shortly after the birth and was treated with antibiotics and fluids. She soon made a full recovery, but Joshua, we were told by staff on the ward, was fine. In the 24 h following Joshua’s birth, we were concerned about his condition. He was breathing quickly, seemed mucousy around his mouth and was struggling to maintain his body temperature. We raised repeated concerns with the midwifery staff that were looking after him. But each time, we were simply reassured he was ok. At 24 h of age, Joshua collapsed with overwhelming sepsis. (We later found out this was the same infection that had caused my wife’s collapse shortly after the birth.)

Joshua’s mother found him blue and …