Reg­u­la­tor says its fail­ings may have left lives at risk in ma­ter­nity unit

The Guardian - - NATIONAL - Frances Per­raudin North of Eng­land reporter

The Nurs­ing and Mid­wifery Coun­cil (NMC) has ad­mit­ted that its fail­ure to promptly in­ves­ti­gate con­cerns over deaths in the ma­ter­nity unit at a Cum­brian hospi­tal may have put lives at risk.

Up to 19 deaths be­tween 2004 and 2012 came as a re­sult of mis­takes by staff in Fur­ness Gen­eral hospi­tal’s ma­ter­nity unit, in one of the big­gest pa­tient care scan­dals in­volv­ing an NHS trust in Eng­land, with six neona­tal deaths, 10 still­births and three deaths of moth­ers.

A re­port by the Pro­fes­sional Stan­dards Au­thor­ity (PSA) pub­lished in May found the lives of moth­ers and ba­bies were “un­doubt­edly put at risk” when the NMC ig­nored Cum­bria po­lice’s ur­gent warn­ings over mid­wives’ ac­tions. The re­port was com­mis­sioned by the health sec­re­tary, Jeremy Hunt, after a 2015 in­quiry found the ma­ter­nity unit had been dys­func­tional and staff were de­fi­cient in skills and knowl­edge.

Con­cerns were first raised after the death of nine-day-old Joshua Tit­combe from sep­sis in 2008, but it was eight years be­fore the NMC ruled that two mid­wives had failed in their duty to prop­erly care for him.

Fol­low­ing publication of the re­port, Philip Graf, the NMC’s chair, ac­cepted there had been fail­ings, but claimed public safety had not been put at risk.

How­ever, an NMC state­ment on Wed­nes­day ac­cepted re­spon­si­bil­ity for all the fail­ings in the re­port. “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. Fur­ther ad­verse events, in­clud­ing one death, oc­curred un­der the care of mid­wives al­ready un­der in­ves­ti­ga­tion by us. The PSA con­cluded that it does not know whether any of these could have been pre­vented.”

The state­ment said that in 2012 “the or­gan­i­sa­tion was fail­ing at every level. We didn’t get things right. We did not lis­ten to fam­i­lies or act on cred­i­ble ev­i­dence from them and others.

“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. We are tak­ing the PSA re­port ex­tremely se­ri­ously... As has been recog­nised, progress has been made since then. But there is much more we can and will do to change and im­prove.”

James Tit­combe, Joshua’s fa­ther, said: “The com­ments from Philip Graf last week stat­ing that safety wasn’t put at risk were truly shock­ing. How­ever, the fact that the NMC have now fi­nally ad­mit­ted that their fail­ures... put the lives of moth­ers and ba­bies at risk is wel­come.”

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