The NMC did not listen to or properly investigate concerns about Midwives at Furness General Hospital.
The Professional Standards Authority for Health and Social Care has today published its Lessons Learned Review which heavily criticises how the Nursing and Midwifery Council handled concerns about midwives’ fitness to practise at the Furness General Hospital.
The review was commissioned by Jeremy Hunt, the Secretary of State for Health and Social Care, after up to 19 babies and mothers died at the hospital between 2004 and 2012 as a result of mistakes by the staff of its maternity unit. A previous inquiry into the deaths concluded that 13 of the infants and women would have lived if they had received better care.
The Review recognises that the NMC has made many changes and improvements since 2014, but concludes that there are two significant areas requiring additional, urgent work: the NMC's approach to the value of evidence from and communication with patients; and its commitment in practice to transparency.
The NMC failed to act on information.
The 80-page makes a series of recommendations and heavily criticises the actions of the NMC after the regulator failed to take any action for two years after information was supplied by the police on maternity staff.
Chief Executive of the Professional Standards Authority, Harry Cayton, said; "What happened at Furness General Hospital remains shocking, and the tragic deaths of babies and mothers should never have happened. The findings in the Review we are publishing today show that the response of the NMC was inadequate.
"Although the NMC has made good progress with its technical handling of complaints and concerns, there remain cultural problems which it must remedy in order for the public to have confidence in its ability to protect them from harm."
We have made improvements.
Responding to the review, Jackie Smith, the outgoing NMC Chief Executive and Registrar said: “The NMC’s approach to the Morecambe Bay cases – in particular the way we communicated with the families – was unacceptable and I am truly sorry for this.
"We take the findings of this review extremely seriously and we’re committed to improving the way we communicate with families, witnesses and all those involved in the fitness to practise process.
“Since 2014 we’ve made significant changes to improve the way we work and as the report recognises, we’re now a very different organisation.
“The changes we’ve made puts vulnerable witnesses and families affected by failings in care at the heart of our work. But we know that there is much more to do."
Lessons have been learned.
Responding to the review, Philip Graf, Chair of the NMC said: “We welcome this review and we will act on the lessons learned, ensuring that the views of families and patients are central to everything we do.
“We will also work closely with the PSA, the professions and other regulators to take forward the report’s important recommendations.”