The watchdog charged with ensuring nurses and midwives in the UK are safe ignored information from the police that may have helped prevent unfit staff from practising, a damning report has found.
Lives were “undoubtedly put at risk” by the failures in the Nursing and Midwifery Council’s (NMC) handling of the Morecambe Bay NHS Trust scandal, where 11 babies and one mother died between 2004 and 2013.
Jeremy Hunt, the health and social care secretary, ordered the review after a 2015 inquiry found serious failings in the clinical competence and integrity of the midwifery unit at the trust’s Furness General Hospital.
The review found evidence that warnings from police went unheeded for nearly two years, and said the NMC has still not addressed cultural failings, which led it to disregard families’ safety concerns, or come clean about its mistakes.
Prior to its publication, the organisation’s chief executive for the past six years, Jackie Smith, announced on Monday that she would be leaving in July.
Families who lost children to care failings at the trust, and have led calls for the NMC to be investigated for its part in the tragedy, said they were “horrified” that police warnings had been ignored alongside their own.
In its report, the Professional Standards Authority (PSA), the watchdog for the UK’s healthcare regulatory bodies, found that the NMC’s response was “inadequate”.
It warned that a lack of clinical knowledge in its investigatory teams, poor record keeping of complaints and investigations and a failure to engage with families and other bodies all contributed to warnings being missed.
These added to the eight-year delay between the first complaints to the NMC and the conclusion of fitness to practise proceedings, meaning midwives who would eventually be struck off continued to practise and in some cases had already retired.
It also includes damning revelations that Cumbria Police had passed on information to the NMC about its own investigations into midwives at the Furness General Hospital maternity unit.
The PSA acknowledges that in some circumstances regulators might postpone their own fitness to practise investigations so as not to prejudice police enquiries.
However, in this instance Cumbria Police expected them to act as its own work would “take years” to conclude, and provided information in April 2012 to enable unsafe midwives to be stopped form working.
Cumbria Police told the PSA investigators: “We were really concerned that reports of the same midwives who we had the cases sitting in front of us were still practising at the hospital.
“I decided that the safeguarding was going to have to trump the investigation at that point, because I felt I had to give some information on these cases to the NMC.”
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However, the report said that there was no evidence this was acted on, adding: “This was an opportunity missed, given that some of the midwives identified by the police were subsequently involved in adverse events at Furness General Hospital.”
The PSA concluded that the NMC has made improvements in “technical areas” like complaint handling and record keeping.
But it added the regulator is still not doing enough to communicate with families and complainants, or to be transparent about its own failings in investigations.
In a joint statement, three of the families whose loved ones died at Furness General Hospital said the report shows “the truly shocking scale” of the NMC’s inaction for the first time.
“We were particularly horrified that even when Cumbria Police directly raised significant issues, the NMC effectively ignored the information for almost two years,” said James Titcombe, Liza Brady and Carl Hendrickson.
“Whilst this was going on, serious incidents involving registrants under investigation continued, meaning lives were undoubtedly put at risk.
“Avoidable tragedies continued to happen that could well have been prevented.”
They added that no big organisation can get “everything right all the time”, but said: “This culture of denial and reputational management is reminiscent of the very worst of the culture our families have experienced over the years.”
Mr Titcombe’s son, Joshua, died after midwives missed chances to spot and treat a serious infection which led to his death from sepsis nine days after he was born at Furness General Hospital in 2008.
The report notes he was seen as “hostile to the NMC corporately” and the NMC monitored his Twitter feed and set up Google alerts on him.
In response to the report, Ms Smith said: “The NMC’s approach to the Morecambe Bay cases – in particular the way we communicated with the families – was unacceptable and I am truly sorry for this.
“We take the findings of this review extremely seriously and we’re committed to improving the way we communicate with families, witnesses and all those involved in the fitness to practise process.
“Since 2014 we’ve made significant changes to improve the way we work and as the report recognises, we’re now a very different organisation.
“The changes we’ve made puts vulnerable witnesses and families affected by failings in care at the heart of our work. But we know that there is much more to do.”
The PSA’s report was triggered after an inquiry found a “lethal mix of failures” led to the scandal at Morecambe Bay, and it triggered a nationwide review of maternity services’ safety.
The chief executive of the PSA, Harry Cayton, said: “Although the NMC has made good progress with its technical handling of complaints and concerns, there remain cultural problems which it must remedy in order for the public to have confidence in its ability to protect them from harm.”
Peter Walsh, chief executive of the patient safety charity Action Against Medical Accidents, said: “The findings of the report are so damning, it can come as no surprise that the CEO of the NMC resigned this week.”