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NMC failed to act on concerns in Morecambe Bay scandal

Nurse regulator must listen to families and improve transparency, says 'lessons learned' report

A damning report says the Nursing and Midwifery Council’s handling of concerns about midwives in the Morecambe Bay scandal was inadequate and tells the regulator to improve transparency as a matter of urgency.


Furness General Hospital, where care failings led to the deaths of at least 19 mothers
and babies between 2004 and 2012. Picture: Alamy

Poor care was linked to the deaths of at least 19 mothers and babies at Furness General Hospital in Cumbria between 2004 and 2012.

In a statement, bereaved families say lives were ‘undoubtedly put at risk’ when the NMC ignored police information about midwives at the hospital, part of University Hospitals of Morecambe Bay NHS Foundation Trust.

Failure to act on information

The report into the regulator’s response to questions about midwives’ fitness to practise reveals the NMC failed to act on police information for almost two years. It noted poor record-keeping, mishandling of bereaved families and long, delayed investigations.

The Lessons Learned report from the Professional Standards Authority (PSA) comes two days after NMC chief executive Jackie Smith announced she will quit in July, after six years in the role.

It says the NMC needs urgently to review and improve:

  • The way it engages with patients and families who complain, so that it considers their evidence, keeps them informed and deals openly with them.
  • Transparency about its errors and its approach to individuals.

The time taken to deal with the cases is ‘an obvious concern’, because midwives who were later suspended or struck off the register continued to practise in the interim.

In one case, it took more than eight years from the first complaint to be made about a midwife for the final fitness to practise hearing to take place.

Concerns raised by police 

The NMC failed to respond appropriately when it received information from patients’ families and the police, the report's authors said.

The NMC appeared to have taken no action for almost two years after the police highlighted concerns about midwives they believed should be investigated, the report adds.

‘This was an opportunity missed, given that some of the midwives identified by the police were subsequently involved in adverse events at Furness General Hospital.’

‘What happened at Furness General Hospital remains shocking, and the tragic deaths of babies and mothers should never have happened’

Harry Cayton, PSA chief executive

The NMC found concerns about fitness to practise proved in four midwives’ cases.

Of those, one was struck off 11 years after the first concerns about her were raised, two were struck off after having retired, and one was suspended for nine months even though the panel found there were no longer any concerns about the safety of her practice.

‘Defensive, legalistic and in some cases misleading’

In a joint statement, Liza Brady, Carl Hendrickson and James Titcombe, all members of patients’ families, said: ‘The NMC has been defensive, legalistic and in some cases grossly misleading in its responses to families and others.’

Mr Titcombe, whose son Joshua died nine days after he was born at Furness General Hospital in 2008, was seen as ‘hostile to the NMC corporately’, the report says, and the regulator monitored his Twitter feed and set up Google alerts to track his activities.

‘It is absolutely right Jackie Smith has stood down; her departure must herald total transformation at the NMC’

John Woodcock, MP for Barrow and Furness

PSA chief executive Harry Cayton said the findings in the report ‘show that the response of the NMC was inadequate’.

‘What happened at Furness General Hospital remains shocking, and the tragic deaths of babies and mothers should never have happened,’ he said.

Significant changes

Responding to the report, NMC chief executive Ms Smith 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 put vulnerable witnesses and families affected by failings in care at the heart of our work. But we know there is much more to do.’

Barrow and Furness MP John Woodcock said: ‘It is absolutely right that Jackie Smith has stood down; her departure must herald a total transformation in culture at the NMC.’

Health and social care secretary Jeremy Hunt said while the NMC had made improvements, it still needed ‘a massive culture change so that families feel they are being genuinely listened to and not just made part of a process’.

The report was discussed among delegates meeting at RCN congress in Belfast. Nurses suggested the college send its condolences to families and work with the PSA to improve the NMC. 

RCN general secretary Janet Davies said: 'We recognise the importance of this report to our profession.

'The PSA says all regulators must be transparent when things go wrong. We work closely with the PSA on its annual performance reviews of the NMC, and have been working with the NMC on the changes to the regulatory framework, to enhance its public protection role, at the same time as improving the process for our members.

'We will continue to work with both PSA and NMC, across all the issues in the report.'  


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