Foreword and summary
We are publishing this report following the completion of three investigations into complaints from three families, all of which related to local midwifery supervision and regulation.
In all three cases, the midwifery supervision and regulatory arrangements at the local level failed to identify poor midwifery practice at Morecambe Bay NHS Foundation Trust. We think these cases clearly illuminate a potential muddling of the supervisory and regulatory roles of Supervisors of Midwives.
Whilst we have found no direct evidence of a conflict of interest in these cases, we think they exemplify the weaknesses in the current regulatory arrangements at a local level. The cases we have seen have also highlighted that the current arrangements do not always allow information about poor care to be escalated effectively into hospital clinical governance or the regulatory system.
We think this means that the current system operates in a way that risks failure to learn from mistakes. This cannot be in the interests of the safety of mothers and babies, and must change.
We have worked with the Nursing and Midwifery Council (NMC), the Professional Standards Authority for Health and Social Care, NHS England and the Department of Health. We have identified two key principles that will form the basis of proposals to change the system of midwifery regulation.
The two principles are:
- that midwifery supervision and regulation should be separated;
- that the NMC should be in direct control of regulatory activity.
We recommend that these principles inform the future model of midwifery regulation.
We recognise that the regulatory framework for midwifery is a UK-wide framework and changes need to be negotiated with stakeholders across the UK. We undertake to share our conclusions and reasoning with the other UK ombudsmen and we look to the Department of Health to convey these recommendations to its counterparts in Northern Ireland, Scotland and Wales.
We recommend that the NMC works together with NHS England and the Department of Health to develop proposals to put these principles into effect. This will include developing and consulting on proportionate approaches to midwifery supervision and midwifery regulation. We recommend that this is done in the context of the anticipated Bill on the future of healthcare regulation. We also recommend that the Professional Standards Authority advises and reports on progress.
Dame Julie Mellor, DBE
Health Service Ombudsman