Kirkup outlines 'lamentable' NMC failures to health secretary

Bill Kirkup, who led the review into maternity failings at the University Hospitals of Morecambe Bay Foundation Trust, said the response to his report published last year by professional regulators had “fallen far short of expectations”.

His letter to Jeremy Hunt, seen by HSJ, follows a decision by an NMC fitness to practise panel to clear two Morecambe Bay midwives, Gretta Dixon and Catherin McCullough, who were accused of misconduct related to the death of baby Joshua Titcombe.

The Professional Standards Authority, which has the power to challenge NMC decisions, said the regulator’s investigation and the panel’s decision was “deficient” because relevant evidence was not presented to the panel by the NMC even though it had it in its possession.

The PSA said on Wednesday that despite the poor handling of the case it was not able to challenge it in law.

Dr Kirkup said in his letter: “The response from professional regulators has fallen far short of expectations. More than 14 months later, two cases have been brought by one regulator. The evidence that was presented in these cases was incomplete in several respects.

“Amongst other things this allowed the registrants’ lawyers to suggest incorrectly that the family’s story had changed significantly three years after the event, as was reported in the press, to the family’s great distress.

“Given the amount of evidence that was already available, the length of time that the NMC has had to prepare since, and the origin of these cases in the well documented serious dysfunction of the maternity unit, this is a lamentable failure.”

The Kirkup report found “failures at almost every level of the NHS” created a “lethal mix”, which caused the avoidable deaths of at least 11 babies and one mother at Furness General Hospital between January 2004 and June 2013.

The letter added: “In the aftermath of the events at Morecambe Bay, there was a pressing need to restore confidence in maternity services, both there and more generally. A vital component in that was a robust investigative process undertaken by the professional regulators that would command the confidence of all those concerned as well as the public.

“That was what I had expected, and I believe it was entirely reasonable for the families to have expected too. It is a matter of significant regret that our expectations have not been borne out by what has transpired.”

He told Mr Hunt his report “was clear that these were significant lapses from the professional duty of NHS staff”.

Following the NMC’s decision families affected by poor care at Morecambe Bay have also written to Mr Hunt asking him to intervene and overhaul the professional regulations system.

The Department of Health said yesterday that it wanted the NMC to review how it treated bereaved families, and it would be consulting on changes to professional regulation later this year.