The Nursing and Midwifery Council failed to listen to or properly investigate concerns about midwives at Furness General Hospital, according to a new report, which concludes the regulator’s handling of the Morecambe Bay maternity scandal was “inadequate” and “frequently incompetent”.
The report into the regulator’s response to questions about midwives’ fitness to practise calls for urgent action to improve the way it deals with people who make complaints, after it found bereaved families were not taken seriously and treated with a lack of respect.
The 84-page Lessons Learned Review – commissioned by health and social care secretary Jeremy Hunt – also said the regulator must take immediate steps to improve “transparency” and be more open and honest about the way it works, including owning up to mistakes.
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It has been published by the Professional Standards Authority for Health and Social Care (PSA) just two days after NMC chief executive and registrar Jackie Smith announced her resignation.
Both she and the NMC were adamant her departure was not linked to the report’s findings, which deal mostly with events that took place before she joined the regulator six years ago.
The review follows a high profile investigation by Dr Bill Kirkup in 2015 into the deaths of mothers and babies at the maternity unit at Furness General Hospital (FGH) in Cumbria, spanning a period of about eight years from 2004 to 2012.
It found a “lethal mix” of failings including poor levels of clinical competence and a culture of denial, at the unit, which is run by University Hospitals of Morecambe Bay NHS Foundation Trust.
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The PSA report, published today, shows the NMC was first alerted to concerns about maternity care at Furness General in 2009, but failed to investigate thoroughly, with inquiries characterised by weak analysis and handling of evidence and poor record-keeping.
“Its handling of the cases before 2014 generally was frequently incompetent”
At least two untoward incidents and one maternal death occurred under the care of midwives already under investigation, found the PSA, which identified a number of “major problems” with the way cases were handled.
“We do not know whether any of these could have been prevented but, in our view, before 2014 the NMC did not take credible information which it received about the midwives at the FGH seriously or take action to satisfy itself that the midwives were fit to practise,” said the report. “Its handling of the cases before 2014 generally was frequently incompetent.”
Even after this time, there were ongoing issues, including the fact cases took longer to be investigated than was necessary “causing distress to families and registrants” and the fact the NMC failed to fully explore the range of misconduct allegedly involved including “clinical concerns, collusion and individual dishonesty”.
In all, the NMC opened 64 complaints against 30 named individuals but went on to impose formal sanctions against just four midwives, one of whom had already retired. The report showed some cases dragged on for years, with the final case only concluded just last year.
Meanwhile, the PSA found “all of the bereaved families were unhappy with aspects of the way in which they were treated or their cases handled by the NMC”.
One of the main criticisms highlighted in the report was the NMC’s failure to engage with families and take their concerns seriously.
“The cases that we saw suggested to us that, culturally, the NMC does not recognises the value that patient and family evidence provides or that patients and families have an interest in cases which, as a regulator, it needs to take seriously,” said the report. “It was not frank and open with them.”
The report showed that the NMC set up Google alerts to track the activities of one bereaved father – referred to as Mr A in the report – and that staff made offensive comments about him.
University Hospitals of Morecambe Bay NHS Foundation Trust
“There are a very small number of emails between staff members which suggest that they found Mr A a nuisance to deal with, were disrespectful about him and gave the impression that he was not seen as someone who had lost a child or had anything helpful to give to their investigations,” said the report.
Another key concern was around transparency and the fact that the regulator did not always live up to the “duty of candour” it expected from nurses and midwives on its registers.
“In our view, transparency involves being open about mistakes, demonstrating learning and can include providing information even where the organisation is not required to do so or where a more restrictive approach is permissible,” said the report, which highlighted a number of instances where the NMC refused to disclose information or admit mistakes.
“The findings in the review we are publishing today show that the response of the NMC was inadequate”
However, the report did acknowledge that the NMC had made “significant improvements” in recent years, including when it came to staff training and support, its investigation and analysis of complaints and work with employers and other regulators.
Positive steps include the establishment of a High Profile Cases Unit to oversee work on potentially complex or controversial cases.
Maternal or baby deaths would now come under the remit of this team, which has dealt with some of the latter stages of the Morecambe Bay cases resulting in limited improvements noted by the PSA.
Intended to ensure strong case management and scrutiny, the PSA said the unit had the potential “to deal more consistently with cases and identify the wider issues” and the team itself reported “significantly greater ownership of cases than was the case previously”.
The NMC is also in the process of establishing a Public Support Service to improve information available to the public on the FtP process, deal with concerns from those who have made complaints and support witnesses in the run-up to hearings.
“We’re committed to improving the way we communicate with families, witnesses and all those involved in the FtP process”
The PSA said the creation of this new service had “the potential to be hugely positive and could be crucial in assisting the NMC to address the very serious concerns we have identified”.
It said the service needed to tackle a number of matters “urgently”, including ensuring decisions were communicated sensitively to those who had raised concerns about nursing or midwifery care.
“In particular, we think that there needs to be greater empathy shown to complainants who have lost loved ones and more accessible explanations of decisions reached at the various stages,” said the report.
It highlighted that the NMC had “yet to demonstrate tangibly that it has properly addressed the need to deal appropriately with patients and families who complain”.
It went on to stress that improvements in this area must not be limited to one service alone but “properly embedded throughout the NMC as whole”.
“The formation of the new service will be pointless if the approach taken by people dealing on a daily basis with patients, families and their complaints is not radically changed,” said the report.
However, it acknowledged that taking forward all of the actions it had identified would require “energy and commitment”.
PSA chief executive Harry Cayton said it was vital that “cultural” issues, in particular, were addressed if the regulator was to move forward.
“What happened at Furness General Hospital remains shocking, and the tragic deaths of babies and mothers should never have happened,” he said.
“The findings in the review we are publishing today show that the response of the NMC was inadequate,” said Mr Cayton.
“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,” he said.
Ms Smith apologised for the NMC’s failings in the handling of the Morecambe Bay FtP cases but said the regulator was now “a very different organisation”.
“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,” said Ms Smith.
“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 said.
Ms Smith said significant changes had been made in the way that the NMC worked with patients and families.
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Source: Andy Paraskos
“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,” she said.
“The changes we’ve made put 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,” she added.
NMC chair Philip Graf said the body would act on the PSA’s recommendations. “We welcome this review and we will act on the lessons learned, ensuring that the views of families and patients are central to everything we do,” he said.
“We will also work closely with the PSA, the professions and other regulators to take forward the report’s important recommendations,” he added.
Janet Davies, chief executive and general secretary of the Royal College of Nursing, said: “We recognise the significance of this report, and its importance to our profession.
“The report identifies some major failures in relation to these particular cases. It also describes significant improvements in the NMC’s fitness to practise procedures since 2014,” she said. “These include new initiatives to improve relations with complainants and their families, through a public support service.
“The PSA says clearly that all regulators have some lessons to learn from the report, and that they must all be transparent when things go wrong,” noted Ms Davies.
She added: “We work closely with the PSA on its annual performance reviews of the NMC, and have been working with the NMC on the changes to the regulatory framework, to enhance its public protection role, at the same time as improving the process for our members. We will continue to work with both PSA and NMC, across all the issues in the report”.