PSA's Lessons Learned Review: The Nursing and Midwifery Council’s handling of concerns about midwives’ fitness to practice at the Furness General Hospital

In May 2018 the Profesional Standards Agency (PSA) published a Review which highlights the lessons learned about the Nursing and Midwifery Council's (NMC) handling of investigations into the clinical competence and integrity of the Midwifery Unit at Furness General Hospital (FGH) following concerns raised by, amongst others, the parents, the Cumbria police and the Kirkup Report (The Report of the Morecambe Bay Investigation chaired by Dr Bill Kirkup, CBE, published in March 2015). This Review makes a harrowing read. It is about 16 babies and 3 mothers who died. It highlights a catastrophic sequence of events where, effectively, no-one took responsibility to investigate concerns and to stop bad practice. It is quite clear that poor clinical practice had been witnessed where babies and women died who need not have died, and that some of the deaths occurred after it was discovered that there was a problem in this unit, including in the years after the Kirkup Report was published.

This Review concentrates on the NMC's "approach to the value of evidence from and communication with patients and the NMC’s commitment in practice to transparency." The Review is long and detailed and describes a time line from 2004 to 2017. I recommend that it is read in its entirety to understand the full failure of all the systems and organisations involved; you may find that you form a different view from that of the many press reports which have been made about various aspects of the many failures.

Section 2 of the Review describes the factual background, and how and when concerns were raised at the FGH. It describes the investigations and the inquests, and the involvement of the NMC and Care Quality Commission (CQC). Cumbria Police investigated clinical concerns which they passed to the NMC and the Ombudsman published reports of investigations, forwarding them to the Strategic Health Authority. The NMC received its first complaint about midwives at the hospital in 2009 and yet it did not complete the process of evaluating these complaints until July 2017, when the Conduct and Competence Committee heard the last of them - 64 in total. The time line in the Appendix of the Review makes for excruciating reading.

This section also describes the Local Supervisory System and the reasons for its subsequent abolishment in 2017, as well as changes to the NMC’s Fitness to Practice system.

Section 3 details the babies and mothers who died and the consequences for the families. The names of the families and the midwives are not released, although they have been in the public domain many times. There is much shocking information about the deaths, the terrible experiences the parents have endured (including not being believed or having had their own evidence not being accepted in the investigations), the useless investigations, the disrespectful midwives and above all the failure of the NMC to ensure the Fitness to Practice of midwives. The midwives, too, were subjected to intense and unnecessary pressure over many years as the NMC failed in their responsibilities to undertake a timely and fair investigation. What was not made clear in most of the media reports was how widespread the failures were. Failures were by no means isolated to the midwifery department - the obstetric team and indeed the Trust management all bear responsibility for these unnecessary deaths.

In 2012, a Freedom of Information Act question about the Midwifery Unit at FGH disclosed that 19 claims had been notified to the NMC in respect of events from 1 January 2009 onwards and that there had been a sharp rise in claims in respect of untoward incidents after 1 January 2007. And yet it was not until June 2015, when the Kirkup report was published and further information received from the Kirkup Investigation team, that a full investigation into the standard of the supervisory reports by the midwives was undertaken by the NMC. Nine supervisory reports were considered by an expert. The investigation took such a long time not least because of difficulties obtaining information from the Trust and the NMC. These included supervisory reports carried out by a midwife in respect of four families. The midwife subsequently admitted her mistakes and agreed that she ought to be struck off. This case was completed eight years after a parent first raised concerns about the adequacy of the midwife’s investigations and five years after the midwife had retired.

Section 4 of the Review focuses on the NMC's "approach to the value of evidence from and communication with patients and the NMC’s commitment in practice to transparency", and what can be learned.

The Review has a series of comments and criticisms about what they found at the NMC but one of the most significant is the one highlighting its lack of clinical knowledge. This is even more profound given that the NMC argued the point with the investigators, maintaining that they didn’t need midwifery clinical advisors. The Review finds that there was a lack of understanding of what the cases were about and why the issues had been raised. This was combined with poor record keeping and communication by the NMC to create a situation which led to disaster.

The Trust’s Head of Midwifery (in Morecambe) told the investigation: "I was dealing with screening people, or investigating managers, or fitness to practice investigators who have no midwifery background or knowledge. And I think that’s the real gap in the NMC as well, that actually some of what we experienced might not have happened if we had actually had the midwifery practitioners doing that screening or the investigation."

The Review also finds that the NMC did not engage properly with the families affected by the events, either in asking them for information, keeping them informed or indeed addressing their concerns. Rather than looking beyond the individual cases, it was found that too much emphasis was put on trying to win the case rather than look at the wider public protection concerns.

The PSA have been very bold in publishing this Review and publically criticising the NMC. The final words in the Review advise the NMC to continue to address its shortcomings. AIMS hopes that the PSA will seriously monitor the new structures and objectives of the NMC to bring about a long-awaited change for the safety of mothers, their babies and midwives.