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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ARM Study Day 2018: Conference Review by Ruth Weston

The 2018 ARM study day in Wigan was described by Dr Lesley Choucri as “Midwifery Nourishment” and I couldn’t agree with her more. This was a wonderful day of learning, sharing and refilling our cups ready to go back to our own regions “Stronger Together”.

“Stronger Together” was one of Kathryn Gutteridge’s themes, which came out of her desire to remind us all that we need to stand together during these challenging times. She pointed out that all midwives are midwives, whether they work for the NHS, private companies or as independent midwives. For the good of the profession – and every midwife – we MUST support each other. There is so much horrific bullying, and areas of practice which are lacking in compassion. Can each person make a change by reflecting on their own practice?

Of course, Better Births was an essential part of the ARM study day, and Claire Mathews , deputy Head of Midwifery for NHS England, outlined its implementation with a focus on Continuity of Carer. Because this was a midwifery audience, Claire focused on the understandable worries that some midwives have of how continuity will work for them, especially as some midwives have experience of continuity services where they were given entirely unreasonable caseloads. With a short-term target of around 20% of women to have continuity, Claire recommended that initially trusts worked on encouraging those midwives who were interested in offering continuity to jump in and have a go, lighting the way for others to follow.

I was particularly struck by Jo Dagustun’s talk on her research into women’s experiences of birth which was an uncomfortable listen for the audience of midwives. Jo explained her PhD research which included women’s experiences of  the maternity system.

The key messages I heard in this excellent, many-layered reflection were:

  • That for women the key antenatal teacher/education was their experience of the maternity system itself.  What women are told in antenatal classes and by professionals about what they can choose, the care they can ask for or receive is over written by actual experience.
  • That women’s experiences of the maternity system, including birth, is of a ‘hostile’ environment; spaces and interactions that do not feel friendly towards the health and wellbeing of mother and baby. Women therefore made decisions on what they saw as the best way of protecting the physical and mental well-being of themselves and their child. Far from this resulting in choices for midwifery led care it often resulted in women choosing a medical birth. It also resulted in women providing partial information or telling professionals what they think is expected rather than the truth.
  • Finally, the women interviewed did not see midwives as a distinct profession with in maternity. Indeed they were not clear what midwives are. Processed through a fragmentary system and seeing multiple professionals, midwives did not stand out. In this context women did not want continuity so much as kindness from the professionals they were with.

This final point provoked a lot of reflection. It is shockingly sad that kindness is not standard in the maternity system. It is also disturbing to realise that midwifery does not stand out to most women in the maternity system. Is this how far the profession has faded? Just another health care professional doing their job? It also has some real consequences for continuity, for instance, who would want continuity from a midwife who did not show kindness?

Finally, Jo, with admirable tact and honesty, presented an example of an interaction between a service user and professionals on social media. What came through to me were professionals who thought they were being kind and helpful but from the service user’s perspective were not. Also, she showed health professionals who wanted the service user to see it from their point of view but did not themselves ‘stand in the shoes of the woman’ – surely a mark of the with-woman profession of midwifery. We need to reflect on how much the maternity system has broken the midwifery tradition of being with-woman and made the midwife a just another health care professional.

In better news, a big shout out needs to happen to Airedale Hospital Trust who have been a shining light on the issue of Independent Midwives and their ability to offer intrapartum care, as Airedale is providing them with indemnity to ensure that they can continue to practice. In return the Trust has these amazing and skilled midwives sharing their experience and knowledge, leading to improved services to women and happier staff. Airedale join several other Trusts across the country who are supporting Independent Midwives in a similar way, as is outlined in the recent IMUK blog.

Aquabirths Hi-Lo Keeling Birth ChairMargaret Jowitt’s Hi-Lo system was on display alongside the Aquabirths stand (see photos to the left for two ways that the Hi-Lo can be used). Also known as the Osborne Kneeling Chair, this wonderful piece of kit is a must for every obstetric room. It is a simple, strong and easily cleaned frame with cushioned supports which women can kneel, lean or sit on. The Hi-Lo is designed to ensure that midwives can easily access women for observations, and the small footprint means that it will fit into most obstetric rooms with ease. A video explaining how the Hi-Lo works is hereSoftbirths Mini birth couch

Aquabirths also had their Softbirths mini birthing couch on display which midwives Deborah Hughes and Deborah Neiger had fun modelling as you can see!  A smaller version of the full birth couch, the mini couch fits into smaller spaces to provide comfort and support to women in different upright birthing positions.

ARM Coordinator, Katherine Hales, rounded off the day with an update on ARM’s campaign for an independent midwifery regulator. The NMC is not fit for purpose as has been discussed on this blog multiple times. ARM now believes that it is essential that midwifery is separated from nursing, and has regulation which focuses on the needs of midwives, which the NMC simply does not do. The focus now is on the midwifery code and midwifery panel being managed by midwives under the umbrella regulation of the Health and Care Professionals Council which oversee many other similar sized groups, such as physiotherapists. This regulator seems to work better to support the professionals it oversees than the NMC does.

All in all, an exceptional day – many thanks to ARM for all their hard work!

#WiganARM18