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Ali Cloak looks at the review of the National Midwifery Council and asks whether they’re doing enough to inspire patient confidence following reports of negligence.
By Ali Cloak
Between 2004 and 2012 up to 19 mothers and babies died due to negligent actions by midwifery staff at Furness General Hospital.
A recent review has heavily criticised the Nursing and Midwifery Council (NMC) – the body responsible for regulating the standard of midwives – for their failure to investigate midwives’ conduct, despite receiving serious complaints from families and reports of dangerous care from the police.
This scandal first came to light in 2015, when an inquiry looked into the circumstances of the deaths of six newborns, three mothers and 10 stillborn babies. The inquiry concluded that 13 of these deaths could have been avoided if the women and children had been provided better care.
One of the cases was the sad death of nine day old Joshua Titcombe caused by midwives failing to notice that he had a serious infection.
Following this inquiry, the Ministry of Health ordered a review into how the Nursing and Midwifery Council (NMC), the body responsible for midwives’ conduct, dealt with the scandal.
This recently released review reveals the police had raised concerns with the NMC about the conduct of midwives and provided them with a list of cases where there were suspicions of poor care. Shockingly, the NMC had taken no action for nearly 2 years, despite having this information.
The review also found that some of the midwives whose conduct was raised by the police, went on to take part in births or care of children where ‘adverse events’ occurred – in other words, where a negative outcome for a mother or child could have been avoided.
It is the NMC’s duty to investigate complaints made against midwives, and where appropriate to instigate disciplinary proceedings and investigate whether a midwife is fit to practice.
The review found that that the NMC had failed to instigate proceedings against midwives at Furness General Hospital, despite the information they received, allowing them to continue practising which created a dangerous environment for pregnant women and their newborns.
The review also found that the NMC had acted inappropriately with families of the deceased mothers and children. It criticised the fact that the NMC did not engage with families to seek information or address their concerns, despite some of these concerns being supported and confirmed by subsequent investigations into the negligent incidents. In particular, the NMC did not investigate allegations that some midwives had been dishonest to families of the deceased women or babies.
A joint statement by three bereaved parents, including the father of Joshua Titcombe whose case is mentioned above, also criticised the way that they were approached by the NMC, calling them “defensive, legalistic and in some cases grossly misleading in their responses to families and others”.
The joint statement said “We were particularly horrified that even when Cumbria police directly raised significant issues, the NMC effectively ignored the information for almost two years. Avoidable tragedies continued to happen that could well have been prevented.”
The review does acknowledge that some of the systems in place at the NMC, which contributed to the avoidable death or injury of mothers and newborns, have been improved since 2014 – a necessary step and welcome news.
However, of most concern to us is that the review has shown that – despite the deaths and despite the inquiry – the NMC is still not recognising the value that evidence from patients and families can bring and continues to not be honest and open with them. The review was concerned that the NMC still cannot deal appropriately with patients and families who make complaints. Clearly, in terms of patient safety, it is imperative that patient’s complaints and concerns are taken seriously and thoroughly investigated.
This culture, which leads to a lack of engagement with patients and families, and it’s approach to transparency where errors have been made, greatly affects those patients and families that interact with the body. This causes the public to lose faith in the NMC’s ability to provide proper standards of nursing and midwifery, something that is required to keep patients safe.
We hope that this comprehensive review will do enough to ensure lessons are learned by the NMC, and that families are spared from these tragedies.
If you have any concerns or wish to discuss any aspect of the report further then please get in touch.