The nursing watchdog ignored grieving families – and even the police – who were warning about failing midwives, a scathing report has found.
It suggested the Nursing and Midwifery Council was more interested in protecting the reputation of nurses and midwives than uncovering poor care.
At least three mothers and 16 babies are thought to have died at a hospital trust between 2004 and 2016 at the hands of a ‘dysfunctional’ gang of ‘musketeer’ midwives obsessed with natural childbirth.
The report commissioned by Health Secretary Jeremy Hunt examined the NMC’s actions during the scandal at the University Hospitals of Morecambe Bay NHS Foundation Trust.
It was carried out by the Professional Standards Authority which regulates the NMC and concluded that the body’s actions were inadequate.
A ‘dysfunctional gang of musketeer nurses’ was said to have caused the deaths of at least three mothers and 16 babies
Families said the NMC had failed to prevent subsequent tragedies by not suspending incompetent midwives.
One of the babies who died in 2008 was Joshua Titcombe whose father James Titcombe is now a high profile patient-safety campaigner.
The 84-page report accused the NMC of failing to engage with families and investigate their concerns.
One mother whose baby was stillborn at the trust in 2004 said the watchdog was shrouded in secrecy and refused to provide any information.
The report also found that the NMC had ignored the concerns of Cumbria police who had launched their own investigation into the maternity unit. The force was worried that midwives under investigation by its officers were still being allowed to work at the trust and deliver babies.
Although the police had hoped the NMC would stop these midwives from practising, it did nothing for two years.
The report also accused the watchdog of dragging its heels over the investigations of the midwives at the centre of the scandal. One was only struck off last year, eight years after a bereaved father had first raised concerns. The deaths all occurred at the Furness General Hospital maternity unit in Cumbria, run by the Morecambe Bay trust.
An initial review published in 2015 blamed the failings on the team of ‘musketeer’ midwives. The year after that report was published another baby died after suffering brain damage due to preventable mistakes.
On Monday the watchdog’s £190,000-a-year chief executive Jackie Smith suddenly announced she will stand down in July. Harry Cayton, chief executive of the Professional Standards Authority, said: ‘What happened at Furness General Hospital remains shocking, and the tragic deaths of babies and mothers should never have happened. The findings we are publishing today show that the response of the NMC was inadequate.
Although the police had hoped the NMC would stop these midwives from practising, it did nothing for two years
‘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.’
A statement released by bereaved relatives James Titcombe, Eliza Brady and Carl Hendrickson said the report exposed the ‘truly shocking scale’ of the NMC’s failings.
‘We were particularly horrified that even when Cumbria police directly raised significant issues, the NMC effectively ignored the information for almost two years.
‘While this was going on, serious incidents involving registrants under investigation continued, meaning lives were undoubtedly put at risk. Avoidable tragedies continued to happen.’
Eliza Brady’s son Alex was stillborn at Furness General Hospital in 2008. Carl Hendrickson lost his wife Nittaya and son Chester that same year due to preventable mistakes.
Three midwives have been struck off for their part in the scandal and one suspended.
Jackie Smith said the NMC was committed to improving the way it communicates.
The report also found that the NMC had monitored Mr Titcombe’s Twitter account and set up ‘Google Alerts’ on him. It said he was regarded as ‘hostile to the NMC corporately’.