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Midwifery regulator to be investigated over handling of Morecambe Bay scandal

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Health secretary Jeremy Hunt has ordered an investigation into the Nursing and Midwifery Council’s handling of the Morecambe Bay care scandal.

The NMC’s investigations are ongoing more than eight years after the first complaints.

The Department of Health has asked the Professional Standards Authority (PSA), which oversees the work of professional regulators, to carry out an independent investigation following ongoing criticism of the NMC’s handling of cases linked to the scandal.

The DH request was made in a letter sent to the PSA on Friday, with the nursing and midwifery regulator’s agreement.

It is understood the investigation will look at how the NMC has responded to concerns raised about midwives at University Hospitals of Morecambe Bay NHS Foundation Trust and the processes it has followed since.

“I now hope that a full and comprehensive investigation will be carried out”

James Titcombe

In the letter, Claire Armstrong, the DH’s deputy director for professional regulation, said: “In order to convey the greatest assurance of independence in such sensitive matter, the department and the NMC believe that the Professional Standards Authority, with its established role in legislation, is best placed to carry out such a review.

“I am therefore writing to you on behalf of the secretary of state to ask whether the authority would be willing to exercise its discretion under the NHS Reform and Health Care Professions Act 2002 and carry out an independent lessons learned review into the NMC’s handling of the Morecambe Bay midwife cases,” she said.

Terms of reference for the review will be agreed with the PSA at a later date.

The NMC is still yet to complete all of the investigations into midwives linked to poor care at the trust, which was at the centre of an inquiry by Dr Bill Kirkup in 2015. His report found failings at the trust led to the avoidable deaths of at least 11 babies and one mother at Furness General Hospital.

NMC chief executive and registrar Jackie Smith has acknowledged the regulator took too long to deal with the cases, after it delayed decisions while other investigations took place.

However, the health secretary has stepped in to request the PSA carries out an independent investigation.

In a statement, Mr Hunt said: “Given the NMC’s importance in ensuring high standards of care in nursing, health visiting and midwifery, this review will provide the public and the NMC itself with independent assurance that all the lessons from its handling of the events at Morecambe Bay have been learned and acted upon.”

The NMC has been in the local and national media spotlight in recent months after it spent almost £240,000 employing a law firm to redact information following a Data Protection Act request from James Titcombe, whose son Joshua died as a result of failings at the trust in 2008.

The regulator has also chosen not to release a report it commissioned examining its decisions over the fitness to practise of midwife Lindsey Biggs, who was involved in Joshua’s care but was allowed to continue working.

She was sacked by the trust last year after another baby died and was subsequently struck off when an NMC panel found her conduct fell well below expected standards.

Last year, the PSA called the NMC’s decision making “deficient” after two midwives were cleared of alleged misconduct linked to Joshua’s death. The panel was not presented with relevant evidence, which prompted Dr Kirkup to write to the DH criticising the NMC.

James titcombe

James titcombe

James Titcombe

The regulator has also been challenged over refusing to reveal allegations against registrants before they appear at fitness to practise panels. Critics said this approach was putting registrant’s reputation above the public interest in such cases.

Mr Titcombe said: “The NMC have badly failed families at Morecambe Bay and I firmly believe that had they acted appropriately, lives would have been saved. Sadly, over the past few years a pattern has emerged that shows an organisation with a poor culture, acting defensively to hide information and protect their own reputation, rather than being open and honest and showing a commitment to learn.

“The recent revelation that they spent £239,000 responding to a routine data protection request by instructing a top city law firm to redact the documents, demonstrates the crisis in leadership and culture that exists,” he told Health Service Journal.

“I now hope that a full and comprehensive investigation will be carried out to get to the bottom of why the NMC have failed mothers and babies at Morecambe Bay so badly and to diagnose the cultural problems in the organisation that have allowed these recent events to happen,” he added.

“We must move forward by identifying how we should do things differently in the future”

Jackie Smith

In a statement, the NMC said that itself and the DH had asked the PSA to carry out “an independent, lessons learned review” into the NMC’s handling of the Morecambe Bay fitness to practise cases.

The regulator noted that it had announced in November that such a review would take place following the conclusion of the final Morecambe Bay fitness to practise cases this year.

Jackie Smith, NMC chief executive and registrar, said: “Following our announcement last year that there would be an independent lessons learned review into our handling of the Morecambe Bay cases, the secretary of state for health and the NMC have asked the PSA to lead this important review.

“As an open and transparent organisation, committed to continuous improvement we welcome the contribution of the PSA in helping us to identify learning from our handling of these cases in order to establish where we could do things differently should a similar situation arise now,” she said.

“As an organisation we have already identified and implemented a range a range of important measures designed to make sure we handle cases better in the future. This includes establishing a dedicated witness liaison service to work closely with the families and individuals contributing to the fitness to practise process,” said Ms Smith.

“We cannot change what has already happened, however, we must move forward by identifying how we should do things differently in the future,” she added.


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