Our report on midwifery supervision and regulation, published in 2013, has led to changes which will make the NHS safer for mothers and their babies.
In our report we highlighted that the safety of mothers and babies could be put at risk because supervisors of midwives have potentially conflicting roles. On the one hand, they support midwives, and on the other they are responsible for investigating serious incidents involving midwives. These could involve the same people they are there to support.
In one tragic case we investigated, a mother died after giving birth, despite attempts to resuscitate her. Her son died the next day because he had been deprived of oxygen during labour. Two supervisors of midwives looked into the case. They reviewed the medical records and decided that there were no midwifery concerns which would warrant an investigation by the supervisors, despite several areas of poor midwifery practice. The lack of a proper investigation meant that the father and his wife’s family had not been able to grieve properly.
We recommended that midwifery supervision and regulation should be separated, and the Nursing and Midwifery Council be put in direct control of regulating midwives. Our report led to an independent review by the King’s Fund, which supported these proposals. The Government has now introduced legal changes that implement our recommendations.