Nursing regulator admits culpability in Morecambe Bay maternity scandal

The nursing regulator has apologised to families affected by the Morecambe Bay scandal admitting that it did not listen or act quickly enough on concerns raised about midwives.

Chairman of the Nursing and Midwifery Council (NMC) Philip Graf told the Health Select Committee that gaps in what the regulator “did and didn’t do” meant mothers and babies were put at risk.

The Committee is examining the NMC’s handling of the midwives embroiled in the scandal where major care failures were linked to at least 12 deaths of mothers and babies at Furness General Hospital (FGH) between 2004 and 2012.

In an opening statement at the start of the hearing, Mr Graf said: “I am extremely sorry for our part in the families suffering over this.

“We didn’t listen.

“When we did listen, we didn’t act quickly enough.

“Those gaps in what we did and didn’t do have caused a risk to families.

“Our listening was simply inadequate.

“The gaps meant there were midwives who were practising who maybe shouldn’t have been practising and therefore mothers and babies were put at risk because of those delays and those gaps.

“We accept completely our responsibility for that.”

It comes after a damning report revealed how the NMC failed to act on information provided by the police for almost two years.

Poor record keeping, mishandling of bereaved families and lengthy and delayed investigations all feature in the Professional Standards Authority (PSA) report.

Days before the report was released in May, Jackie Smith announced she was stepping down as chief executive and registrar of the regulator.

The PSA report concluded that the length of time taken to deal with the cases is “an obvious concern” – it took more than eight years between the first complaint being received by the NMC and the final fitness to practise hearing for one of the midwives involved.

The delay meant that midwives who were later suspended or struck off the regulator’s register continued to practise.

Meanwhile, the PSA said that the NMC lawyers did not identify key issues from information in its possession, not only from the families involved, but also from the police.

The panel of NMC officials were probed by MPs on the Health Committee as to why they didn’t act on information supplied to them by police.

Cumbria Police told the PSA: “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.”

The police handed the NMC information highlighting concerns about the midwives they believed should be investigated. The NMC appeared to have taken no action on the list for almost two years after being given the information, the PSA report states.

Ms Smith told MPs: “The fact is that we took too long and we allowed other people to do whatever it was they were going to do while we sat back and waited. The effect of that is that it took us years to deal with these cases and that presented a risk. What’s clear in the PSA report is we would not now do that.”

She told MPs that in 2010 when she joined the organisation as director of fitness to practise, case officers were holding 200 to 300 cases each.

In 2012, the entire organisation was “failing” she added. She said the watchdog had “no money” which led to nurses and midwives having their registration fees increased.

Mr Graf told MPs: “We have however, I believe, made significant progress and the PSA report recognised that.

“We have made progress in terms of our relationship in dealing with families, in our work with trusts and employers to spot problems earlier.”

But Mr Graf added: “We did not cause the deaths of those babies.

“Without wishing to sound defensive there were other actors involved, in terms of the trust, before it came to us.

“Our delay in dealing with the cases probably led to midwives who shouldn’t have been practising, practising. But we were not responsible for the deaths of those babies.”

Ms Smith, who leaves her role in a fortnight after six-and-a-half years at the helm of the organisation, added: “The facts are that we took too long and that created a risk. In an ideal situation what you would have is an event happening like this and the trust investigating it immediately and dealing with the event there and then because they are best placed to do it.

“Only after that situation if there remains a patient safety risk it would come to us. Of course that wasn’t what happened here. The trust didn’t do an investigation which could be relied upon.”

On her resignation, she added: “I didn’t think it was necessary for me to resign on the basis of the contents of the report, but I did think it was right for the NMC and others to move on.”


The culture of the nursing and midwifery regulator has been called into question over “disrespectful” remarks that some staff made about a bereaved father.

A Professional Standards Authority (PSA) report criticised the Nursing and Midwifery Council’s (NMC) handling of the Morecambe Bay scandal where major care failures were linked to at least 12 deaths of mothers and babies at Furness General Hospital (FGH) between 2004 and 2012.

The PSA report, published in May, highlighted how James Titcombe, whose son Joshua died after midwives missed chances to spot and treat a serious infection which led to his death nine days after he was born at FGH in 2008, was seen as “hostile to the NMC corporately”.

The NMC monitored his Twitter feed and set up Google alerts on him, the report states.

The document also highlighted how a small number of emails between NMC staff members suggested that they found him “a nuisance to deal with, were disrespectful about him and gave the impression that he was not seen as someone who had lost a child or had anything helpful to give to their investigations”.

Speaking before the Health and Social Care Select Committee, the regulator told MPs that there was “no corporate decision” to monitor Mr Titcombe.

Meanwhile, individuals who sent the emails were “spoken to”, MPs were told.

Dr Paul Williams, Labour MP for Stockton South, said: “What is wrong with the culture of your organisation that there are people within the organisation making disparaging, disrespectful remarks about people that have suffered great tragedy?”

Outgoing chief executive and registrar Jackie Smith said: “It is a terrible situation, it shouldn’t have happened. We wouldn’t want staff members making those comments, it is horrible for Mr Titcombe.

“It shouldn’t happen. I sincerely hope it will never happen again. Those individuals have been spoken to. It is appalling for Mr Titcombe and I deeply regret it.”

Matthew McClelland, director of fitness to practise at the NMC, added: “There were a small number of emails and we spoke to those people to reinforce the fact that was completely unacceptable. Some of those people are no longer with the organisation.”

When asked about the monitoring of Mr Titcombe, Ms Smith said: “There wasn’t a corporate decision to monitor individuals.”

She added: “Every organisation has a regime in place to understand what is being said about it.

“What our media team does is look at all sorts of people and what they are saying because it is relevant to how we are taking forward the work that we are doing.”

MPs were told how after the PSA report was published, the NMC started a programme of work of recognising the value that patients and family members bring.

After the hearing, Mr Titcombe tweeted: “Over the years I’ve had so many exchanges with Smith, trying desperately to argue that putting the FGH cases on hold was the wrong thing to do & that lives were at risk. She treated me with utter contempt & I absolutely believe that lives were lost as a consequence.

“When the evidence that more lives had indeed been lost whilst the NMC did nothing emerged, instead of being honest – the NMC responded with spin & PR, focusing on their reputation rather than what they needed to learn.”

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