Comment

New legislation puts safety at the heart of midwifery regulation

Landmark legislation separating the development and regulation of midwives will improve the safety of mothers and babies and further support midwives to learn from mistakes, says Parliamentary and Health Service Ombudsman Dame Julie Mellor. 
Midwifery-Alamy.jpg

Landmark legislation separating the development and regulation of midwives will improve the safety of mothers and babies and further support midwives to learn from mistakes, says Parliamentary and Health Service Ombudsman Dame Julie Mellor

NHS midwives do a fantastic job caring for mothers and babies, but when mistakes are made, they must be properly investigated, so that lessons can be learned.

This is why todays announcement of landmark legislation to separate the development and regulation of midwives is so important, helping to further improve the safety of mothers and babies and ensure standards remain high.

Supervisors are currently responsible for developing and supporting midwives, but they can also be asked to investigate serious incidents involving the same midwives. This puts them in the difficult position of

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Landmark legislation separating the development and regulation of midwives will improve the safety of mothers and babies and further support midwives to learn from mistakes, says Parliamentary and Health Service Ombudsman Dame Julie Mellor 


There have been significant failings in investigations involving midwives,
putting women and babies at risk. Picture: Alamy 

NHS midwives do a fantastic job caring for mothers and babies, but when mistakes are made, they must be properly investigated, so that lessons can be learned. 

This is why today’s announcement of landmark legislation to separate the development and regulation of midwives is so important, helping to further improve the safety of mothers and babies and ensure standards remain high.

Supervisors are currently responsible for developing and supporting midwives, but they can also be asked to investigate serious incidents involving the same midwives. This puts them in the difficult position of having to carry out two inherently conflicting roles.

Investigative failings 

Robust and effective investigations can only happen if they are independent. Sadly, we have seen significant failings in investigations involving midwives, putting women and babies at risk.

In one tragic case, complications during a mother’s labour meant the baby did not have enough oxygen during birth and was stillborn. The midwife who investigated the death did not identify the failings in care, including why electronic foetal heart monitoring was not started when the baby’s heart was beating faster than normal.

Supervisors should have started the local investigation within 20 days, but we found it was seven months before it was started, which was difficult for the family. The investigation was not independent, and subsequent reports failed to identify that midwifery care fell short of guidelines and good practice.

In another heartrending case, a mother died after giving birth despite resuscitation attempts. Her son, who had been deprived of oxygen during labour, died the next day. 

Modernising regulation

Two midwifery supervisors looked into the case and decided there were no midwifery concerns to warrant an investigation, despite several areas of poor midwifery practice. We found that supervisors should have identified a number of failings, particularly as the mother had a high risk pregnancy. 

In our 2013 report on midwifery supervision and regulation, we recommended that the Nursing and Midwifery Council be in charge of all regulatory activity. This would remove any conflict of interest and enable supervisors to focus on supporting midwives in their roles, including professional development. 

Today our recommendations have become reality, helping to modernise the regulation of the profession and bring it in line with nurses and doctors. 

This legal milestone puts safety at the heart of midwifery regulation and will further support midwives to learn from mistakes.


Dame Julie Mellor is Parliamentary and Health Service Ombudsman

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