Post PSA report – is the NMC Fit to Practice?

 

Guest blog by Emma Ashworth

The Professional Standards Agency (PSA) is the organisation whose role it is to oversee the regulators, such as the NMC. In May 2018 the PSA released a report into the NMC’s handling of the deaths of women and babies at Morecambe Bay’s Furness General Hospital.

Background
Between 2004 and 2016, in Morecambe Bay, Lancashire, UK, there were deaths of a woman and 11 babies during birth and the early postnatal period, where families were left with concerns over whether the level of care given by staff at the Trust was acceptable. Some of these families worked very hard over the subsequent years to try to establish what truly happened to their loved ones, and eventually an investigation was instigated by the Secretary of State for Health, and was run by Bill Kirkup, CBE. The full Kirkup report can be read here: Click for Kirkup Report Link

Media mis-representing of “normal birth at any cost”
There is no doubt that the Kirkup report is hard reading. Much of the media picked up on various terms and phrases were repeated ad nauseam (and continue to be portrayed, erroneously, as actual findings from the report) such as “normal birth at any cost”. This refers to a quote from the report by Lindsey Biggs, a midwife later struck off by the NMC over cases which were looked at in the Kirkup report, where she is reported to have said, “there were a group of midwives who thought that normal childbirth was the… be all and end all… at any cost… yeah, it does sound awful, but I think it’s true – you have a normal delivery at any cost”. 

Systemic problems at the Trust
The majority of the media and other discussions following the Kirkup report were focused on blaming the midwives for their actions. There is no doubt that there were midwives whose practice was severely impaired and in some cases was found to be contributory to the deaths of babies and women (1), but the problems at the Trust were systemic, all the way through from midwives to doctors to management. Kirkup states, “we were dismayed to hear the extent to which obstetricians, midwives and paediatricians had allowed the breakdown of personal and interdisciplinary relationships to jeopardise care.” (2) and he reports on, “suboptimal care in which different management would reasonably have been expected to make a difference to the outcome.” (3). Furthermore, Kirkup’s report states, “[the 2010 report] contained significant criticisms of the Trust’s maternity care, including dysfunctional relationships, poor environment and a poor approach to clinical governance and effectiveness. The report was given very limited circulation within the Trust, and was not shared with the NW SHA until October 2010, or with the CQC and Monitor until April 2011. Although we heard different accounts, and it was clear that there was limited managerial capacity to deal with a demanding agenda, including the FT application, we found on the balance of probability that there was an element of conscious suppression of the report both internally and externally.” (4) There is no doubt that some midwives in Morecambe Bay were found to have failings serious enough to mean that they were no longer permitted to practice midwifery, however the media almost entirely missed the fact that vast swathes of the Trust were also responsible for what happened, including what appears to be a deliberate cover-up according to Kirkup.

Due to the fact that the problems found by Kirkup were caused by both clinical staff of various disciplines and management staff, there was no single body which was able to do a level of investigation into the problems as a whole, nor a single organisation that the parents could complaint to and obtain an investigation into their cases. The midwives were referred to the NMC, but the NMC’s processes were so flawed that by the time it got to the end of the fitness to practice investigations, at least one of the midwives had retired, and was no longer on the register (5). Other failing parts of the Trust were not covered by the NMC’s investigation as their remit only covers midwives, leaving the parents in limbo between multiple organisations.

Professional Standards Agency Report
In May 2018, the PSA published its investigation into the NMC’s handling of the cases of the midwives of Morecambe Bay. The report was nothing short of catastrophic, showing that the NMC failed to protect the public – its stated aim – and also to appropriately support midwives, putting them through hellish and absolutely unnecessary delays during fitness to practice proceedings.

Not only were the NMC’s processes catastrophically flawed, the way that they responded to the grieving parents was horrific. Again, not only did the NMC fail to protect the public from midwives who were eventually found to be “not fit to practice” but they failed to protect them from the abuse that they received from the NMC itself.

One family’s experiences outlined within the PSA report (Mr and Mrs A) explain how initially the NMC decided that there was no case to answer against the midwives, including one or more who were eventually struck of the register. This happened because the family’s statement appears to have been disregarded in the face of contrasting evidence from the midwives themselves, the local investigations and the Trust’s own statements. Any discrepancies between these accounts were not addressed (6). The father continued to press for answers and over a year later, the NMC discussed the issues, referred the case to the CQC and decided to await the police report which was now underway (7). The father continued to send evidence of what he considered to be collusion between the midwives involved, some of which was dismissed by the NMC, and the rest appears to have been forgotten until yet another three years had passed, when the cases were finally looked at again – by which time one of the midwives had retired from practice anyway (8).

Two years MORE passed, and eventually two of the midwives came in front of a fitness to practice (FtP) panel. Over seven years had now passed since the death of Mr and Mrs A’s baby boy. Seven years for the parents to continue to fight and for the midwives to have the case hanging over their heads. Yet at this hearing, much of the parents’ evidence was not even put before the panel. During the hearing, Mr A specifically gave the NMC the missing evidence but they still refused to admit it, stating that it would not be likely to affect the outcome (9). If this wasn’t enough for the parents to endure, Mr A was informed that he must refer to his dead son as “baby A” during the hearing – which he quite rightly refused to do.

Following the hearings, Mr A continued to raise concerns with the NMC about its actions, or lack of them. He decided to make a Subject Access Request (SAR) under the Data Protection Act, and received, in the documents package, copies of papers which included discussions within the NMC about him which were offensive in nature (10), and pages of redactions which included one page with the entirety of the text covered up other than Mr A’s own name (11).

Mr A is quoted as saying that he, “…felt hopeless and that they were just following a process for the sake of following it. It felt like nobody really cared about what they were doing. Nobody understood that there might be mothers and babies at risk and it was like an administrative process that nobody really cared about.” (11)

This is not the NMC protecting the public.

The report goes on to discuss the cases of six further catastrophic incidents at Morecambe Bay, and how the NMC failed to protect the public.

We hoped that we were on the cusp of change, with a new CEO being put into place after the last one, Jackie Smith, resigned the day before the PSA report was published!  Yet the new Chair of the NMC, Philip Graf, apparently dismissed the findings of the PSA report out of hand by saying, upon its publication, that “public safety was not put at risk” (12) by delays by the NMC in dealing with complaints against the Trust. Graf U-turned on this position a few days later when he admitted:

“Multiple opportunities to take action were missed, we didn’t investigate concerns and when we did, we took too long. We are very sorry for this.
Due to our failures to act and the resulting delays in our investigations and hearings, some midwives continued to practise who may not have been safe to do so and mothers and babies may have been at risk of harm during this period.”

Does this mean that the NMC are starting to reflect on their failings?

The recent resignation of Midwife Helen Shallow as Midwifery Education and Policy Advisor to the NMC (her 11 page resignation letter was discussed in the Nursing Times (13)) following her appalling experiences within the organisation, midwives and birthing women alike are not holding their breath that they will be able to expect proper regulation and protection anytime soon. When Dr Shallow states that she felt registrants were seen virtually as “the enemy” by the NMC, and that midwives are “somehow inherently not to be trusted or a potential adversary who must be kept in check at all times” we should be very concerned indeed that the NMC really is Not Fit to Practice.

References:

  1. Kirkup report, page 12
  2. Kirkup report, page 13
  3. Kirkup report, page 9
  4. https://www.professionalstandards.org.uk/docs/default-source/publications/nmc-lessons-learned-review-may-2018.pdf?sfvrsn=ff177220_0 Para 3.27
  5. PSA report, page 15
  6. PSA report, page 16
  7. PSA report, page 16
  8. PSA report, page 18
  9. PSA report, page 57
  10. PSA report, page 61
  11. PSA report, page 25
  12. https://www.channel4.com/news/parents-says-regulator-has-not-learned-lessons-after-baby-deaths
  13. https://www.nursingtimes.net/news/professional-regulation/exclusive-expert-midwife-attacks-nmc-in-explosive-resignation-letter/7024875.article

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Imposter Syndrome and the fear that we’re not quite good enough…

“There is freedom waiting for you,
On the breezes of the sky,
And you ask “What if I fall?”
Oh but my darling,
What if you fly?” 
Erin Hanson

Emma Ashworth talks about imposter syndrome in maternity services and why we should face the fear of not being good enough.

Years ago, I spoke to a midwife who had been hosting a weekend’s training course with the truly wonderful Sheila Kitzinger. I was really saddened to find that I’d missed the course, and said so to the midwife, saying that I was a huge fan of hers. He replied that yes, she is amazing, and yes, I’d missed a fabulous weekend, however he told me something that I’ve never forgotten. He said that we’re all amazing. We’re all doing amazing things, and to never, ever forget the impact that each and every one of us has on those who we support, and the changes that we make.

And yet – that feeling remained of being surrounded by giants whose shoes I will never even be able to step into, let alone fill. That fear that those around me know more than me; that I’ll say something silly or not understand something, and be “found out” remained. For a long time it meant that I didn’t always call out things that I knew to be wrong, such as some of the proclamations made by obstetricians who graced us with their presence at MSLC meetings. I was already one of the lowly lay, the only unpaid group of people in the room, the tick box attendees. How much worse if they realised that actually I didn’t know as much as they did about obstetrics!

Then one day, I discovered that there is an actual name for this. It’s called “imposter syndrome” and it is where we feel that we are less skilled, less knowledgeable and less valuable than we actually are.  It’s where we feel that we’ll get found out, discovered, seen to be fraudulently taking up a position that we have too little knowledge about. Suddenly, learning that this was a “thing” made me realise that in fact I was not alone in how I felt and therefore perhaps what I felt was simply wrong. Perhaps those in the room felt the same way. Perhaps the obstetricians don’t’ expect me to know what they know – because why would I – but perhaps I have knowledge that they have no idea about, and that is scary for them, too. And it’s true, I do. I know how women experience interactions with them, and what happens before and after those interactions. I know how the way that they speak to women can lead to peace or trauma. I know that their actions or words can impact on a life forever, and I know that they know that I know this!

When the Emperor has no clothes, and the trusts and CCGs try to push through blatantly unreasonable service changes or guidelines, it doesn’t need an expert to point out the naked truth about the damage that these changes often cause. We don’t need to be experts in anything to be the one to call out where the NHS is making damaging decisions. Even if we’re really new to working in maternity campaigning, we have our own experiences and our own innate knowledge which is the most powerful knowledge there is. None of us are imposters. Every one of us has value and every one of us can shake off the imposter syndrome niggles, and walk tall into our own area of campaigning. We may be worried that we will fall, but, oh, what if we fly?

I recently came across another blog on this very issue, by Dr Joanna Martin. She’s written a lovely piece which has some great ideas about what you can practically do to overcome imposter fears. Have a read of it here.