The Nursing and Midwifery Council (NMC) describes its role on its own website as being a body which ‘exists to protect the public’.
It says it has ‘clear and transparent processes to investigate nurses and midwives who fall short of standards’, with a ‘mission statement’ claiming it will ‘take action if concerns are raised about whether a nurse or midwife is fit to practise’.
Today, those words sadly ring ever so hollow following a Professional Standards Authority (PSA) review which said its failings in investigating concerns at Furness General Hospital led to ‘tragic deaths of babies and mothers which should never have happened.’
Failures at the hospital were linked to at least 12 deaths of mothers and babies at between 2004 and 2012, and now a ‘lessons learned’ report has revealed the how the NMC failed to act on police information for almost two years in relation to concerns about midwifes.
Poor record keeping, mishandling of bereaved families and lengthy and delayed investigations were highlighted as reasons for midwives being allowed to continue in their roles for many years before being suspended or struck off the regulator’s register.
The report reveals it took more than eight years between the first complaint being received by the NMC and the final fitness to practise hearing for one of the midwives involved.
Of four cases where the NMC found concerns about the midwives’ fitness to practise to be proven, one took 11 years after concerns were first raised for the midwife to be struck off.
A second was struck off five years after she had retired, and a third was suspended for nine months and a fourth was struck off also having retired.
The report said further avoidable deaths occurred while the NMC were considering the complaints.
Shocking lack of urgent action led to a continuing pattern of errors costing lives
Perhaps the most shocking revelation is the fact that the NMC took almost two years to act on information which had been given to it by Cumbria Police, which had raised concerns around ‘reports of the same midwives who were still practising at the hospital.’
The report concludes the length of time taken to deal with the cases was “an obvious concern” leading to the NMC apologising and admitting its handling of the Morecambe Bay NHS Foundation Trust cases was “unacceptable”.
The matter has led to chief executive Jackie Smith quitting her role also, but it is all sadly too little, too late.
The failure of the watchdog to act at the appropriate time led to a continuing pattern of fundamental errors by midwives costing lives.
Apologies and talk of lessons learned will offer little comfort to those who lost loved ones, including James Titcombe, whose son Joshua died after midwives missed chances to spot and treat a serious infection.
It has been revealed the NMC monitored his online activity as he was seen as ‘hostile’ towards it, also setting up ‘Google alerts’ on him and spending £240,000 on lawyers in order to withhold information from him.
Such actions could hardly be any further away from its own pledge of protecting the public and its ‘values’ – again detailed on its website – of believing people matter, being open and honest and acting with integrity.
Mrs Smith’s last words before resigning were that the NMC was now a ‘very different organisation’ having made ‘significant changes since 2014’.
That is certainly to be hoped so, as over this lengthy time period where lives were being lost and avoidable tragedies which could have been prevented continued to happen, the watchdog quite clearly failed to fulfil its primary role.
This must now act as a warning to other watchdogs across all areas of the health sector about the need to act quickly, strongly, decisively and transparently when there are any concerns over any matter which could impact on patient safety.