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Regulator to review lessons that can be learnt from Morecambe Bay scandal

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The Nursing and Midwifery Council is to carry out an assessment of what lessons it can learn from its involvement in investigations into care failings that led to the deaths of babies at Morecambe Bay NHS Foundation Trust.

The regulator said that once all fitness to practise cases against midwives from the trust had concluded next year, it would commission an independent review.

“I’m really determined that we do learn those lessons and that we involve the families”

Jackie Smith

NMC chief executive and registrar Jackie Smith said at a council meeting this week the aim was to “look at what the NMC would do now if faced with the situation”.

Last year a major independent review of the trust from 2004 to 2013, which was led by Dr Bill Kirkup, found “serious and shocking” failures at almost every level, from the maternity unit to regulators.

It concluded this “lethal mix” of problems across the system had contributed to the unnecessary deaths of at least one mother and 11 babies.

A series of fitness to practise cases against midwives linked to care failings at the trust have been taking place since last year.

The first of those, against midwife Marie Ratcliffe – a former band 7 midwife at Furness General Hospital – resulted in her being struck off, while other cases are ongoing.

However, the NMC has received criticism along the way for how it has dealt with the process.

“There are cases where we do have to wait… that’s not ideal for anyone and it’s really distressing”

Jackie Smith

Earlier this year, the Professional Standards Authority criticised the NMC for its “deficient” handling of the case against two Morecambe Bay midwives who were cleared of alleged misconduct linked to the death of baby Joshua Titcombe in 2008.

In an interview with Nursing Times this week, Ms Smith noted the complexity of the investigations surrounding Morecambe Bay and the number of different agencies involved.

She said that in the past the regulator had waited for other agencies – such as the police – to act first before it had carried out its own investigations.

Ms Smith said this was not the NMC’s approach now, but that part of the independent review would look at whether it could make further improvements in this area.

She also said the review would look at how witnesses were taken through proceedings.

Nt editorial jackie smith

Nt editorial jackie smith

Jackie Smith

“The NMC has in the past always waited for people to do their bit first,” she said. “That is not the approach we take now.

“But there is no doubt that if we find ourselves in a situation whereby we can definitely learn lessons from the way in which we have either waited or been passive or inactive, or even how we’ve taken witnesses throughout the proceedings, we need to say ‘hang on a minute, I’m sure there are things we could do better’,” she said.

She said the regulator wanted to apply any recommendations from the review to its wider work.

“We need to see how we apply this more broadly,” she said. “Because there are cases where we do have to wait, which means by the time we get round to dealing with it they are old. And that’s not ideal for anyone and it’s really distressing.

“So, what could we do differently in the future – bearing in mind the constraints of our legislation? And what lessons do we need to learn? And I’m really determined that we do learn those lessons and that we involve the families,” she added.

Earlier this week, the NMC announced that Dr Kirkup, who led the investigation into maternity failings at University Hospitals of Morecambe Bay Foundation Trust, had joined its midwifery panel.

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