• NMC heavily criticised by Professional Standards Authority over its handling of Morecambe Bay complaints over eight years
  • Regulator failed to act on concerns, did not take families seriously and was not transparent
  • Key evidence was lost and police concerns not acted on with midwives later involved in poor care

The Nursing and Midwifery Council put the public at risk from poor care after ignoring more than 20 concerns raised by the police for two years, a damning report has revealed.

The Professional Standards Authority said the regulator took no action when Cumbria Police raised concerns about the conduct of midwives at the University Hospitals of Morecambe Bay Foundation Trust.

University Hospitals of Morecambe Bay NHS Foundation Trust

Cumbria Police was concerned about the safety of patients at Furness General Hospital in 2012

Some of the midwives flagged by police were later involved in poor care at the trust, including one patient death.

The PSA said the delays in investigating cases meant midwives who were subsequently suspended or struck off continued to practise. Others left the register or retired, which meant their conduct could not be investigated.

The findings are part of a report into the NMC’s handling of the Morecambe Bay scandal. It revealed numerous failures by the NMC including “frequently incompetent” handling of complaints, poor behaviour by staff towards families, reluctance to take concerns seriously and lack of openness about mistakes it made.

The PSA also found evidence of documents being lost, information being withheld and action was not taken when it should have been.

NMC chief executive Jackie Smith announced her resignation on Monday.

The report reveals that in 2012 Cumbria Police was so concerned about the safety of patients at Furness General Hospital that it supplied the NMC with more than 20 cases where it felt there were safety concerns.

The report said: “The NMC appears to have taken no action on the list for almost two years when, as the police told us, the point of providing the information was to enable the NMC to consider whether urgent action ought to be taken.”

The delays meant midwives “continued to practise who may not have been safe to do so”. The report said: “Untoward incidents involving two of the registrants noted on Cumbria Police’s list took place after the NMC had received the information from the police and that those midwives were subsequently struck off (one for incidents that took place after that list had been received)…

“From our study of the files we were aware of at least two further untoward incidents and one death under the care of midwives who were already under investigation after 2013.”

The report added: “We cannot say that members of the public raising complaints with the NMC will feel confident that their concerns are being addressed or treated with an appropriate level of respect or that the NMC will be frank with them where things go wrong.”

The NMC was also found to have lost key evidence and was not open about this, which the PSA said was a “matter of considerable concern”. James Titcombe, whose son Joshua died in 2008 after being born at Furness General Hospital, provided the NMC in 2010 with a chronology of what happened written shortly after his son’s death but this was lost and not shared with a fitness to practise panel in 2016.

In a letter to the health secretary, the NMC then claimed it did consider the chronology before the hearing and it was not clear when it was written. The PSA said the document was clearly dated November 2008. It added: “The NMC was unable to provide us with a definite answer as to what happened to the chronology. The NMC has told us… there is a significant likelihood that the chronology was lost at an early stage and that the first time that it came to its notice was when [Mr Titcombe] presented it at the hearing.”

The PSA said this was at least evidence of poor record keeping and failure to enquire after “what might have been an important, near contemporaneous piece of evidence”.

It added: “We could see no evidence of the NMC seeking to satisfy itself as to what had happened about the chronology at the time, even though [Mr Titcombe] had raised the question with the chief executive directly.”

Ms Smith told the PSA the regulator had failed to “manage [Mr Titcombe’s] expectations” and it was clear to her from 2014 that the NMC could not deliver what he wanted.

In response, the PSA said: “We think [Mr Titcombe] was asking the NMC to look at serious and evidenced concerns about the competence and conduct of the midwives at Furness General Hospital and whether they were safe to practise. We do not think that it was unreasonable for him to expect that the NMC would do so. The problem was that the NMC did not take proper account of his concerns, did not communicate well with him and was not open with him about the problems with their investigations in the early years.”

Most important findings in the PSA report

  • A “very poor” standard of record keeping, which the PSA said “raises the possibility that there is other material that we have not seen and that the NMC is not aware of”.
  • The NMC lacked clinical knowledge in its fitness to practise teams and had overreliance on local investigations. It also failed to engage with issues raised by families or Cumbria Police.
  • One father, whose wife and baby died at Morecambe Bay, was not interviewed by the NMC’s lawyers, who the PSA said “dismissed his concerns”.
  • Discrepancies between statements from midwives were not addressed because “no one seems to have examined those statements to see whether discrepancies existed and, if so, how serious they were”.
  • The NMC had evidence of midwives being dishonest that was not “investigated adequately” and “never formally explored”.
  • Treatment of some families was “well below acceptable standards of treatment” even when the NMC knew it had made mistakes in the initial investigations.
  • The PSA said it saw documents showing the NMC monitored Mr Titcombe’s Twitter feed, quotes he gave to the media and set up Google alerts about him. Internal emails discussed how to “handle him” and there were a small number of “offensive comments” about him between members of staff.
  • The NMC did not disclose documents it should have done under a Data Protection Act request including some that contained “puerile, disrespectful comments” about Mr Titcombe.

In its conclusions, the PSA said the NMC’s “handling of the cases before 2014 generally was frequently incompetent. Even after that, cases took longer to be investigated than was necessary causing distress to families and registrants”.

James titcombe 3x2

James Titcombe: ‘The NMC failed families at Morecambe Bay and put lives at risk’

It added: “The full range of the conduct allegedly involved – clinical concerns, collusion and individual dishonesty – was not fully explored… The families we spoke to were dissatisfied and our study of the files showed that all of the bereaved families were unhappy with aspects of the way in which they were treated or their cases handled by the NMC…

“Taking these actions forward will need energy and commitment and will require some cultural change within the organisation. These matters are serious and need to be addressed urgently if the NMC is to maintain public confidence in it as a regulator.”

Mr Titcombe said: “The NMC failed families at Morecambe Bay and put the lives of mothers and babies at risk. Even when they would have been only too aware of this, instead of being open and honest with families they were defensive, hurtful and outright dishonest with them about the problems.”

Carl Hendrickson, whose wife Nittaya and son Chester died at Morecambe Bay in 2008, said he was angry and believed the behaviour of the NMC had amounted to misconduct in public office. He said: “I can’t believe they could behave like that. The role of the NMC is to protect the public but they were protecting the midwives. It has completely undermined the NMC.”

Philip Graf, chair of the NMC, said: “We welcome this review and we will act on the lessons learned, ensuring that the views of families and patients are central to everything we do.

“We will also work closely with the PSA, the professions and other regulators to take forward the report’s important recommendations.”