Professional Standards Authority Review: Furness Baby Deaths

Professional Standards Authority

The Professional Standards Authority for Health and Social Care has today published its Lessons Learned Review into handling by the Nursing and Midwifery Council (NMC) of concerns about midwives’ fitness to practise at the Furness General Hospital (FGH). These concerns date back to 2004.

The review found:

  • Individual midwives were alleged to have been dishonest in the accounts they gave to local investigations and in their responses to NMC inquiries.
  • Some midwives were alleged to have colluded to present distorted evidence to the coroner’s inquest.
  • A Midwife was dishonest to individual parents when discussing the causes of the babies’ deaths and in her supervisory reports.
  • Cumbria Police did not wish to reveal material to the NMC that might find its way to the registrants – the NMC had made it clear that, if it received information relevant to a complaint, then it would disclose that to the registrants concerned.
  • The NMC understood that the police did not think it was appropriate for them to interview witnesses, other than Mr A, and particularly not the registrants (though the NMC has no power to interview registrants) but that the police had no objection to it investigating the “NMC shit” emails and, when it arose, Mr B’s case. The NMC’s external lawyers advised that this was as far as it was appropriate to go.
  • At meetings with Cumbria Police in 2011 and 2012, the NMC indicated that it would find evidence from the police useful in order to assess whether it needed to take action to protect the public.
  • Cumbria Police provided information to the NMC in April 2012 about more than 20 cases where they considered that there were concerns about the midwives that should be investigated.

This Review, commissioned by the Secretary of State for Health and Social Care, and supported by the NMC has concluded that, although the NMC’s performance as a regulator is improving, it continues to make some mistakes and must develop a more respectful and open culture.

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 Review makes a series of recommendations intended to aid the NMC and other regulators to improve their standards. These are focused on ways to improve engagement with patients and the public and to act in a transparent fashion.

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.”

  • You can download a copy of the report here. For media enquiries please call 020 7618 9118 or email [email protected]

About the Review

This Review was commissioned by the Rt Hon Jeremy Hunt MP, Secretary of State for Health and Social Care, following an investigation by Dr Bill Kirkup CBE, concluded in 2015, which found serious concerns about the clinical competence and integrity of the midwifery unit at Furness General Hospital between 2004 and 2014. The Authority was given the remit by the Secretary of State to examine the NMC’s approach to managing the complaints, its administration of the cases and its relationship management with witnesses, registrants and other key stakeholders. The Authority was asked to identify lessons which the NMC and other regulators could learn from the handling of these cases. The NMC has cooperated and supported the review.

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