Beverley Beech summarises the HIW's report into the case of Clare Fisher and the failings of the LSA

Focussing on the failings of the LSA in the case of Clare Fisher: The Healthcare Inspectorate Wales’ report (2013)

Summarised by Beverley Beech

In 2013, Healthcare Inspectorate Wales published findings that did not surprise anyone who had been supporting Clare through her years of mistreatment by the regulatory system. They offered, at last, an official account of failings by regulatory bodies, bodies which exist not to mistreat midwives but to protect the public. Here are some extracts from that report:

“With regard to the Local Supervising Authority’s (LSA) handling of matters relating to Clare Fisher, my findings demonstrate a significant failure by the LSA to routinely and consistently uphold the standards and requirements set for its operation by the NMC and Health Inspectorate Wales (HIW). In particular, I identified significant weaknesses in the adequacy of the systems and processes as they were applied in this case, alongside a failure by some individuals to uphold the professional values and ethics established both for the midwifery profession and HIW. In particular, I identified:

• A failure to set out clearly and consistently for the individuals involved the framework of standards and guidelines governing the exercise of statutory supervision in Wales by the LSA
• A failure to maintain adequate records supporting the LSA’s decisions and actions
• A failure to provide information and communicate effectively
• A failure to identify and manage conflicts of interest
• A failure to ensure actions were taken on a timely basis, in accordance with prescribed timescales
• A failure to ensure investigations were carried out to professional standards
• A failure to take appropriate action in response to complaints received
• A failure to operate openly and transparently
• A failure to demonstrate equity and impartiality; and
• A failure to demonstrate learning and improvement as a result of review and investigation findings and recommendations.” (p13-14)

“Based upon my findings overall, I am unable to provide assurance that Clare Fisher has been treated fairly, equitably and objectively by the LSA in Wales. The records do not confirm that staff were impartial. The records do indicate failings in earlier reviews and investigations carried out on behalf of HIW. The LSA’s actions in this one case was neither professional nor accountable. This has been to the detriment of the midwives involved (most notably Clare Fisher herself), public protection, and the reputation of the LSA in Wales.” (p14)

“The serious nature of my findings relating to the period 2008-10, together with the earlier finding of maladministration made by the Public Services Ombudsman for Wales with regard to specific events prior to 2008 must in my view call into question the overall reliability of the LSA’s dealings with Clare Fisher.” (p14)

“The failures in this one case are extensive. The resulting action to address the issues raised must be proportionate, timely and appropriate to the current operation of the LSA in Wales.” (p14)

“With regard to the specific findings relating to the role and actions of individuals involved in this case, where information has previously been provided to professional bodies such as the NMC or others about the LSA’s dealings with Clare Fisher, and upon which these bodies may have made decisions or otherwise taken action, these bodies should be notified of the relevant findings of this review.” (p18-19)

Extracts from: Health Inspectorate Wales (2013) Midwife CF: Desk top review of HIW 's actions. Full report. July 2013, pp520