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NMC responded inadequately to midwife failings in Furness

Tragic deaths of babies and mothers should never have happened, concludes review into regulator’s approach

Louise Prime

Wednesday, 16 May 2018

The Nursing and Midwifery Council (NMC) responded inadequately to concerns about midwives’ fitness to practise at Furness General Hospital and ‘the tragic deaths of babies and mothers should never have happened’, according to a review by the Professional Standards Authority (PSA). It said today that despite some improvements the regulator continues to make some mistakes. The NMC has apologised and pointed to significant improvements that it has put in place since 2014.

An investigation led by Dr Bill Kirkup CBE, concluded in 2015, found serious concerns about the clinical competence and integrity of the midwifery unit at Furness General Hospital between 2004 and 2014. It identified at least 20 instances of significant or major failures of care associated with three maternal deaths, ten stillbirths and six neonatal deaths at the hospital between 2004 and 2012; and suggested that a different result might have been expected in 13 of these cases had there been different care.

The health secretary Jeremy Hunt commissioned this review by the PSA to examine the NMC’s approach to managing the complaints, its administration of the cases and its relationship management with witnesses, registrants and other key stakeholders; and also to identify lessons that the NMC and other regulators could learn from its handling of these cases. The PSA reported in its Lessons Learned Review, published this morning, that:

  • The NMC’s record keeping was poor.
  • Individuals did not analyse cases properly or consider their implications.
  • Information from third parties or elsewhere in the NMC was not properly analysed or acted upon.
  • The NMC did not take information from the families seriously or engage with them properly.
  • When criticised or asked to provide information, the NMC adopted a defensive approach, even if it intended to be transparent.
  • The fitness to practise system itself is unsuitable for dealing with a number of the concerns noted in the Kirkup report.
The PSA recognised that the NMC’s performance as a regulator is improving, and that it has made many changes and improvements since 2014. But it also said the NMC continues to make some mistakes and must urgently review and improve both: its engagement with patients and families who complain, including valuing their evidence; and its approach to transparency about its errors and its approach to individuals.

PSA chief executive Harry Cayton, said: “What happened at Furness General Hospital remains shocking, and the tragic deaths of babies and mothers should never have happened. The findings in the review we are publishing today show that the response of the NMC was inadequate.

“Although the NMC has made good progress with its technical handling of complaints and concerns, there remain cultural problems which it must remedy in order for the public to have confidence in its ability to protect them from harm.”

The NMC said it welcomed the PSA’s review into its handling of these fitness to practise cases in Morecambe Bay, and apologised for its failings. But it also pointed out that since 2014 it has introduced a new public support service to support vulnerable witnesses and families through the fitness to practise process and a new employer link service; significantly improved its record keeping; consulted on proposals for a total overhaul of its approach to fitness to practise; and achieved its best ever performance review from the PSA.

Jackie Smith, NMC chief executive and registrar, said: “The NMC’s approach to the Morecambe Bay cases – in particular the way we communicated with the families – was unacceptable and I am truly sorry for this.

“We take the findings of this review extremely seriously and we’re committed to improving the way we communicate with families, witnesses and all those involved in the fitness to practise process.”

She added: “Since 2014 we’ve made significant changes to improve the way we work and as the report recognises, we’re now a very different organisation. The changes we’ve made puts vulnerable witnesses and families affected by failings in care at the heart of our work. But we know that there is much more to do.”

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