Regulator misled health secretary over safety scandal

The Nursing and Midwifery Council (NMC) misled former health secretary Jeremy Hunt over its handling of fitness to practise cases linked to the Morecambe Bay maternity scandal, an independent report has said.

In a letter to Mr Hunt, the nursing regulator’s former chief executive Jackie Smith said a document relied on by the family of one baby who died at the hospital had been considered by its lawyers ahead of a fitness to practise panel.

Now a new report by consultancy Verita said the regulator had in fact lost the document and it was not considered ahead of the fitness to practise hearing. It said the misleading letter was “obviously concerning” and criticised the regulator for its poor practice in not checking documents.

Verita’s report, commissioned by the NMC and published today, has also laid bare how the nursing regulator badly treated the parents of Joshua Titcombe, who died in October 2008 after poor care at Furness General Hospital. It concluded they were “unfairly attacked” in the press.

Joshua’s father James Titcombe provided the NMC in 2010 with a chronology of what happened after his son’s death (written in 2008) in which it was mentioned that both he and his wife had been unwell before Joshua’s birth. This document was lost and not shared with a fitness to practise panel in 2016 with lawyers claiming the couple were unreliable witnesses.

The report claims the errors were the result of “mainly accidental factors, combined with poor communication and management” at the regulator.

It found the chronology document was never included in the original case file for the NMC, which was not noticed by NMC staff.

Mr Titcombe, whose campaign about maternity safety at the Cumbria hospital led to the Kirkup inquiry being published in 2016, told HSJ: “Verita seem to have gone about this in a way that their objective was to provide an innocent explanation. The investigation doesn’t seem very logical and the report has changed significantly from earlier versions with significant criticisms removed.

“If you wanted to design a process that tortured bereaved parents you couldn’t do much better than the process the NMC came up with. We were made to relive what happened again and again and when the hearing eventually took place, attempts were made to discredit our evidence with no one from the NMC challenging statements that were plainly untrue.”

He said the actions of the NMC after he raised concerns made the situation worse: “I knew that the excuses given at the time made no sense, but the fact that it took an external investigation before we were told the truth, is something that still shocks me.”

A report by the Professional Standards Authority last year found the NMC had put the public at risk of poor care and was guilty of “frequently incompetent” complaint handling.

The former chief executive Jackie Smith resigned last year. Former chair Dame Janet Finch was replaced by Philip Graf in May 2018.

Andrea Sutcliffe, new chief executive of the NMC, said: “Throughout these fitness to practise cases the way we treated Mr Titcombe and his family was unacceptable. Our actions made an awful situation much worse and I am very sorry for that. I am also very sorry that our communications with Mr Titcombe, the PSA and the secretary of state for health and social care contained incorrect and misleading information about our handling of this evidence.

“Together with NMC Chair Philip Graf, I am writing to Mr Titcombe, the chief executive of the PSA and the current and former secretary of state to apologise for these errors which should not have occurred.”

She said the investigation highlighted a number of failings for the regulator which “reflected a culture at the NMC at that time that prioritised process over people. When concerns were raised with us about our approach, we acted defensively and dismissed those concerns. That is frankly unacceptable.”

The regulator has since made changes, she argued, including better record keeping, a new public support service and better training for panel members to appreciate the needs of witnesses.

She added: “While I am clear that, if faced with the same situation again, we would do things differently, I am also very aware that for many of those going through our fitness to practise process, it remains a very difficult experience. That is why we are carrying out further work, to understand how we can better ensure that witnesses, particularly those in vulnerable circumstances, are able to give evidence in a way that causes as little distress as possible. This includes learning from other organisations and jurisdictions, such as the courts.

“I know that this investigation does not address all of Mr Titcombe’s concerns and I am sorry for that. However, I am grateful for his continued engagement and support as we change and improve. I would like to pay tribute to him for the passion and determination he has shown to ensure women, babies and their families have the safest, best care possible – an objective shared by all of us at the NMC. I am absolutely committed to learning the lessons of the past, taking forward the recommendations of this investigation and building on recent improvements as we look to develop a just, learning culture, both within the NMC and the wider health and care system.”

Read Verita report

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Source: HSJ, 23 October 2019