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Kate Stone

Posted 16 May 2018
by Kate Stone

Furness Hospital Baby Deaths: Midwifery Council Criticised

baby and mothers.

A recently published report by the Professional Standard Authority concluded that the midwifery regulator had taken too long to act on concerns about midwives at the Furness General Hospital in Cumbria which may have led to “avoidable deaths”.

An independent investigation chaired by Dr Bill Kirkup published in March 2015 had previously found that there had been a “lethal mix” of failures in a “seriously dysfunctional maternity unit” at the hospital. 20 instances of significant major failures of care associated with three maternal deaths and the deaths of 16 babies at, or shortly after, birth were identified. The investigation concluded that different clinical care in these cases would have been expected to prevent the outcome in 1 maternal death and the deaths of 11 babies between 2004 and 2013.

Failings were found at every level from the maternity unit itself to those responsible for regulating and monitoring the trust running the unit, including: –

  • substandard clinical competence
  • extremely poor working relationships between different staff groups
  • repeated failure to investigate at first instance properly and to learn lessons

Dr Bill Kirkup described a “distressing chain of events” which had led to avoidable harm. He described a catalogue of missed opportunities by the NHS trust, the regional Health Authority and 4 national bodies which should have identified and acted on failings. He said that failure of care was still occurring after 2012, some 8 years after the initial warning event and over 4 years after the dysfunctional nature of the unit should have become obvious.

Since this investigation, a Professional Standards Authority review has found that the Nursing and Midwifery Council (NMC) failed to react quickly enough to concerns from police and families.

The recent Professional Standards Authority report was critical of the NMC for the 8-year delay in initiating “fitness to practice” hearings against a number of midwives after concerns were initially raised. Three midwives have since been struck off and a fourth has been suspended.

The NMC has apologised and admitted that its approach was unacceptable. The NMC Chief Executive Jackie Smith has announced that she will leave her post in July 2018.

During the course of investigations, it was noted that the shocking events had only been brought to light thanks to the efforts of some diligent and courageous families who consistently refused to accept what they were being told. The NMC has reported that it has learnt from mistakes made and it is good to note that changes have now been made to put vulnerable witnesses and families affected by failings at the heart of their work.

Read the article here

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About the author

Kate Stone

Kate Stone


Solicitor in the medical negligence team