Flawed local regulation of midwifery services can place the lives of mothers and babies at risk, according to a report published today by the health service ombudsman.

The report summarises three investigations by the ombudsman into care standards following the deaths of three babies and a mother at University Hospitals of Morecambe Bay Foundation Trust and notes that statutory supervision of midwives consistently failed to identify poor practice.

The report concludes that persistent failure to answer affected families’ questions and a failure to learn from poor midwifery care were common themes across all of the cases.

In one of the incidents investigated the mother had diabetes and was undergoing an induced labour which meant her baby’s heart should have been monitored regularly. The report concluded that “the fact that this wasn’t done should have prompted a decision to investigate”. However, no supervisory investigation was undertaken and the North West Strategic Health Authority in place at the time ruled this decision was sound.  

The ombudsman found investigations done internally were not thorough and that “assumptions were made” about the care given. In one incident a supervisory investigation should have started within 20 days but instead took seven months to get underway.

After consulting with leaders in the field of midwifery and regulation the ombudsman’s report proposes that midwifery regulation and supervision should be separated. It also recommends that the Nursing and Midwifery Council should have direct control of regulatory activity.

The report suggests the Nursing and Midwifery Council works together with NHS England and the Department of Health to develop proposals to put these principles into effect. 

The report also recommends that this is done in the context of the anticipated parliamentary bill on the future of healthcare regulation and that the Professional Standards Authority advises and reports on progress.

Parliamentary and health service ombudsman Dame Julie Mellor said: “We think that there are real weaknesses in the statutory arrangements for the local supervision of midwives which risk failure to learn from mistakes. This cannot be in the interests of mothers and babies or of midwives and must change.”

Dame Julie concluded that the role of midwife supervisors in investigating incidents alongside supporting colleagues professionally “leads to an inherent conflict of interest which can put at risk the ability to identify and learn from mistakes and make midwifery services safer in future”.

She added that “in other regulated professions these two roles of regulation and support are separate”.

A statement from the affected families said that while they “welcome these recommendations wholeheartedly” the length of time it took to thoroughly investigate their complaints “highlights serious flaws and bias against patients who have suffered harm in the NHS and have sought to ensure their concerns were properly investigated and acknowledged”.

The families argue that the report “reveals the systematic failure of the [North West SHA] to properly investigate maternal and infant deaths following care at Furness General Hospital”.

They add: “Not only did the SHA fail to investigate the deaths properly, they responded to a legitimate complaint about the failure to do so by commissioning a review that was never likely to address the concerns even before it started.”