The government will initiate an overhaul of midwife supervision and has called for the nursing code to be reviewed to ensure staff are encouraged to reveal concerns rather than “cover them up”.
The moves were announced by health secretary Jeremy Hunt today in response to the Kirkup report on maternity care failings at the University Hospitals of Morecambe Bay NHS Foundation Trust.
The report was commissioned by Mr Hunt in September 2013, after years of campaigning by parents about incidents surrounding the deaths of women and babies at the trust dating from 2004.
“Nothing we say or do today can take away that pain. But we can… try to prevent a similar tragedy in the future,” the health secretary told the House of Commons in a statement.
“The report exposed systemic issues about the quality of midwifery supervision”
He also apologised on behalf of the government and the NHS to “every family that has suffered as a result of these terrible failures”. But he noted that Morecambe Bay was “not typical” of NHS maternity services.
“Our dedicated midwives, nurses, obstetricians and paediatricians work extremely long hours providing excellent care in the vast majority of cases,” he said.
“Today’s report is no reflection on their dedication and commitment. But we owe it to all of them to get to the bottom of what happened so we can make sure it never happens again,” he added.
Mr Hunt pledged that the government would examine the Kirkup report’s 44 “excellent” recommendations in detail before providing a full response to the Commons. But he also highlighted “some actions that I intend to implement immediately”.
He told MPs he had asked NHS England medical director Professor Sir Bruce Keogh to review the professional codes of “both doctors and nurses and to ensure that the right incentives are in place to prevent people covering up instead of reporting and learning from mistakes”.
“For this vital work he will lead a team which will include the Professional Standards Authority, the General Medical Council, Nursing Medical Council and Health Education England, and will report back to the Health Secretary later this year,” he said.
This was sparked, he said, by suggestions that medical notes were destroyed and mistakes covered up at Morecambe Bay.
Mr Hunt also told MPs that the report had exposed “systemic issues” about the quality of midwifery supervision.
He highlighted the recent review of midwifery regulation carried out by the King’s Fund for the NMC, which recommended that “effective local supervision needs to be carried out by individuals wholly independent from the trust they are supervising”.
“No one should lose their job for an honest mistake made with the best of intentions”
He said: “The government will work closely with stakeholders to agree a more effective oversight arrangement and will legislate accordingly.
“I have asked for proposals on the new system by the end of July this year,” he added.
In addition, Mr Hunt cited actions being taken because the NHS was “still much too slow” at investigating serious incidents involving severe harm or death.
“The [Kirkup] report recommends much clearer guidelines for standardised incident reporting which I am today asking Dr Mike Durkin, director of patient safety at NHS England, to draw up and publish,” he said.
Mr Hunt said Dr Durkin would also look into the possibility of setting up a service for the NHS similar to that for airline accident investigations.
“Serious medical incidents should continue to be instigated and carried out locally, but where trusts feel they would benefit from an expert independent national team to establish facts rapidly on a no-blame basis they should be able to do so,” he said.
Mr Hunt also noted that the NMC was already investigating the fitness to practise of seven midwives who worked at the trust during the time of the failings discussed by the Kirkup report.
“They will now forensically go through any further evidence gathered by the Investigation to ensure that any wrongdoing or malpractice is investigated,” he said. “Anyone who is found to have practised unsafely or who covered up mistakes will be held to account.”
“Every midwife and nurse has a responsibility to speak up when things go wrong”
NMC chief executive and registrar Jackie Smith said the Kirkup report had made”very significant” recommendations, which it would “consider carefully”.
“Every midwife and nurse has a responsibility to speak up when things go wrong and the work we are doing with the GMC on the duty of candour [for health professionals] will reinforce that duty to speak up,” she said.
“We are pleased that the inquiry and the Department of Health have acknowledged the need to remove supervision from our legislation,” she said. “With the necessary and long overdue changes to our legislation, we can make further improvements.”
The trust itself was put into special measures in June 2014 following visits by the Care Quality Commission. It will be re-inspected this summer, said Mr Hunt.
“The whole house will want to support [the trust’s] frontline staff in their commitment and dedication during this difficult period,” he said.