Editorial Monday 21 December 2015: 'Joshua's Story' by James Titcombe

It would be far, far better for James Titcombe and his family if this book hadn't had to be written. Tragically, Joshua's Story did have to be written.

James Titcombe's powerful, pacy writing is all the more effective for being clear-eyed. The admirable strength of his character in wanting Joshua's avoidable death to be a catalyst for change, honesty and learning is a vivid contrast to the greyscale obfuscations, half-truths, insults and outright lies he repeatedly encountered.

I slightly dreaded starting the book: having admired his campaigning and enjoyed meeting and interviewing him, I didn't want the book to be less than competently written.

It is more than competently written: he takes us through events with the right level of detail. The reader shares the increasingly frantic fear as Joshua deteriorates: when eventually he gets competent care, it is too late.

The pacing of the book is impressively like a good crime thriller, which is arguably what it was.

The nightmarish world of the traditional NHS approach to complaints is skewered beautifully. Successful campaigners need the poise of perspective to be all over the detail and indefatigable, without falling into the bear-trap of obsession.

One of the key lessons that NHS organisations could learn from 'Joshua's Story' would be to review serious incidents and complaints with a genuine open mind as to whether poor care may have happened, both to apologise, remedy and learn to prevent repetition. It is wholly clear that Morecambe Bay saw an unacceptable clinical culture cause many avoidable deaths of children.

Another lesson for the NHS might be 'don't treat grieving families with near-contempt'. Granted, many people would be less educated, safety-conscious (as a nuclear plant inspector must) and determined than the author, but there is an unsettling tone, best shown in internal documents mocking and insulting the Titcombe family.

Titcombe is generous in acknowledging those who helped expose the truth, even if they took some convincing.

The Kirkup Report brings the facts to clear light, but only a measure of closure.

Nobody has yet been prosecuted for the avoidable deaths of children, let alone the tawdry efforts to cover up unsafe care.

As parents, James and Hoa are the ones who get the life sentence. Joshua got a short life and painful death - and a powerfully told book. It's scarcely justice.