Babies’ lives could have been saved if a health watchdog had acted quickly on police concerns about midwives, a report has concluded.
A review into the Nursing and Midwifery Council’s (NMC) handling of the Morecambe Bay scandal – where failures were linked to at least 12 deaths of mothers and babies at Furness General Hospital (FGH) between 2004 and 2012 – revealed how the NMC failed to act on police information for almost two years.
Poor record keeping, mishandling of bereaved families and lengthy and delayed investigations meant that midwives who were later suspended or struck off the regulator’s register had continued to practise.
The Professional Standards Authority (PSA) “lessons learned” report concludes that the length of time taken to deal with the cases is “an obvious concern”.
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.
Cumbria Police told the PSA: “We were really concerned that reports of the same midwives – who we had the cases sitting in front of us – were still practising at the hospital.”
The NMC has admitted that its handling of the Morecambe Bay cases was “unacceptable” and has apologised.
But in a statement by some of the parents affected – including James Titcombe, whose son Joshua died after midwives missed chances to spot and treat a serious infection – said: “Today’s report from the PSA details, for the first time, the truly shocking scale of the NMC failure to respond properly to the serious concerns and detailed information provided to them relating to the safety of midwifery services at Furness General Hospital.
“We were particularly horrified that even when Cumbria Police directly raised significant issues, the NMC effectively ignored the information for almost two years… meaning lives were undoubtedly put at risk.
“Avoidable tragedies continued to happen that could well have been prevented.”
Mr Titcombe was seen as “hostile to the NMC corporately”, prompting it to monitor his Twitter feed and set up Google alerts on him.
Before the report’s release, Jackie Smith, the chief executive of the NMC, announced she was quitting.
She admitted: “The NMC approach to the Morecambe Bay cases – in particular the way we communicated with the families – was unacceptable and I am truly sorry for this.
“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 NMC found concerns about the midwives’ fitness to practise were proven in four cases.
One midwife was struck off 11 years after the first concerns about her were raised, a second was struck off five years after she had retired, and a third was suspended for nine months – even though the panel found there were no longer any concerns about her. The fourth was struck off having also retired.
“Further avoidable deaths occurred while the NMC were considering the complaints,” the report said.
The chief executive of the PSA, Harry Cayton, said: “What happened at FGH remains shocking, and the tragic deaths of babies and mothers should never have happened.”
A 2015 inquiry found a “lethal mix” of failures at the University Hospitals of Morecambe Bay NHS Foundation Trust had led to the unnecessary deaths of 11 babies and one mother between 2004 and 2013.
Barrow and Furness MP John Woodcock said: “This devastating report shows how local families were systematically obstructed and failed by an organisation whose conduct has brought shame on the proud and vital profession it is supposed to represent.”