Inspection and Regulation

18.07.18

NMC admits it ‘sat back’ during Morecambe Bay scandal, recognises big culture shift ahead

The nursing regulator has apologised to families affected by the Morecambe Bay scandal and has said its listening to concerned parties was “simply inadequate” – but argued that it was not responsible for the deaths of children at the maternity unit.

Philip Graf, chairman of the Nursing and Midwifery Council (NMC), its now-resigned chief executive Jackie Smith, and director of fitness to practice Matthew McClelland were questioned by the Health and Social Care Select Committee on the scandal that led to as many as 12 preventable deaths at Furness General Hospital between 2004 and 2013.

An 80-page review from the Professional Standards Authority (PSA) in May found that the NMC failed to react in time to concerns of family members and the police, echoing an inquiry led by Dr Bill Kirkup in 2015 which found that a “lethal mix” of failures at University Hospitals of Morecambe Bay NHS Trust led to the unnecessary deaths of 11 babies and one mother.

Delayed investigations such as taking as long as two years to act on police information, poor record-keeping, and mishandling of grieving families were cited as reasons that led to the major scandal of midwives who were deemed to have ‘covered up’ poor practice when performing duties at the hospital.

Speaking to MPs yesterday, Graf accepted the PSA’s assertion that some midwives were deemed unfit to practice and consequently put lives at risk. He admitted that staff shortages meant that some of the midwives who were practising at Furness “maybe shouldn’t have been practising.”

The chairman noted that the NMC’s listening to concerns of close parties was “simply inadequate,” but said later in the session that the organisation was not the cause of the deaths of the babies at the trust.

“We did not cause the deaths of those babies,” he explained. “There were other actors involved in terms of the trust before it came to us. Our delay in dealing with the cases led to midwives who probably shouldn’t have been practising to be practising.

“Therefore, there was for sure an increased risk— but we were not responsible for the deaths of those babies.”

Smith, who will leave the organisation in two weeks following a six-and-a-half-year tenure leading the NMC, also admitted that the regulator “sat back” in acting upon police and public queries about midwifery practice, whilst agencies such as the CQC, Lancashire Police, and Kirkup himself evaluated the practise at the trust.

“We took too long and we allowed other people to do whatever it is that they felt they needed to do whilst we sat back and waited. The effect of that was that it took years to do over these cases, and that presented a risk,” she continued.

“We missed the people that mattered here— if we’re going to make a difference going forward, we have to listen people, and that is going to take time because it’s going to take a big shift in the way in which we do things.”

Smith added that when she joined the NMC in 2010, ‘fitness to practise’ cases of members of the council were taking a massive five years to be completed, as opposed to the 18-month process it is now.

On progress made by the council since the scandal, Graf told MPs: “We have made significant progress and the PSA report recognised that.

“We have made progress in terms of our relationship in dealing with families, and in our work with trusts and employers to spot problems earlier.”

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