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University Hospitals of Morecambe Bay Foundation Trust

Ombudsman calls for overhaul of midwife regulation system

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The current system of midwifery regulation and supervision should be separated in the wake of care failings at Furness Hospital, according to the health service ombudsman.

Flawed local regulation of midwifery services can place the lives of mothers and babies at risk, the ombudsman Dame Julie Mellor warned in a report today.

The report – Midwifery supervision and regulation: recommendations for change – follows the deaths of three babies and a mother at the hospital, which is run University Hospitals of Morecambe Bay Foundation Trust.

It summarises the conclusions of three investigations by the ombudsman, which found local statutory supervision of midwives consistently failed to identify poor midwifery practice.

The report concluded that unanswered questions and a failure to learn from poor midwifery care were common themes across all of the cases.

In one incident, the mother had diabetes and was undergoing an induced labour. Her baby’s heart was not monitored regularly, but no supervisory investigation was undertaken into the incident.

In another incident, a supervisory investigation should have started within 20 days, but instead took seven months to get underway.

The ombudsman found investigations done internally were not thorough and that “assumptions were made” about the care given.

After consulting with leaders in the field of midwifery and regulation, the ombudsman’s report proposed that midwifery regulation and supervision should be separated. It also recommended that the Nursing and Midwifery Council should have direct control of regulatory activity.

The ombudsman’s report said the NMC should work together with NHS England and the Department of Health to develop proposals to put these principles into effect. 

The report also recommends this is done in the context of the anticipated parliamentary Bill on the future of healthcare regulation and that the Professional Standards Authority advises and reports on progress.

Dame Julie said: “We think that there are real weaknesses in the statutory arrangements for the local supervision of midwives, which risk failure to learn from mistakes.

“This cannot be in the interests of mothers and babies or of midwives and must change,” she added.

Dame Julie concluded that the role of midwife supervisors in investigating incidents alongside supporting colleagues professionally “leads to an inherent conflict of interest which can put at risk the ability to identify and learn from mistakes and make midwifery services safer in future”.

She added that “in other regulated professions these two roles of regulation and support are separate”.

However, the Royal College of Midwives cautioned against moving away from the present system of supervision and regulation.

RCM chief executive Cathy Warwick said: “Midwifery supervision is a statutory function, is highly-valued by the midwifery profession and, indeed, has been the envy of other professional groups. It is impartial, in that it does not represent the interests of any service provider.”

Professor Warwick noted that the framework had undergone change since the Morecambe Bay complaints arose and it believed “significant steps” had already been taken to address some of the ombudsman’s concerns.

“In many maternity services, the supervision of midwives can and should make a significant contribution to the protection of women and their babies,” she said. “It is very important that the long-term consequences for high-quality maternity care of further changes are very carefully considered.”

She added: “We must be extremely careful not to lose sight of the benefits of midwifery supervision; we could be in danger of throwing the baby out with the bath water.”


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