Findings of independent review into handling of Morecambe Bay evidence

Published on 23 October 2019

23 October 2019

Last year the Professional Standards Authority (PSA) report into our handling of the Morecambe Bay fitness to practise cases identified some outstanding questions around what happened to a piece of evidence – a chronology – prepared by Mr Titcombe (referred to as Mr A in the report) with his wife, following the tragic death of their son Joshua.

As a result of those questions we asked an independent organisation, Verita, to look at what happened to the chronology and how our communications around that came to be inconsistent.

It is clear from the investigation that we got a number of significant things wrong in our handling of this evidence, the way we reacted when concerns were raised with us and our subsequent communications. This includes:

  • Not receiving from our external solicitors, in 2010, the dated chronology provided by Mr Titcombe at an early stage of the evidence gathering process and then failing to understand that it was missing from the case papers at any time up to the hearing in 2016.
  • Failing to consider and understand the significance of this evidence and its relevance to a central issue in the case.
  • Not taking sufficient steps to ensure that, while giving evidence during a hearing, witnesses were treated with the respect and sensitivity they deserved.
  • Not giving proper consideration to concerns raised about our approach to this evidence by Mr Titcombe and acting defensively when those concerns were raised with us.
  • Including incorrect and misleading statements around our receipt and consideration of the chronology in letters to Mr Titcombe, the PSA and the Secretary of State for Health in 2016.

The independent investigators also made two recommendations for the NMC:

  • The NMC should ensure that Panel Chairs are fully briefed about the importance of showing respect to bereaved relatives, perhaps by using this example as a case study.
  • The NMC should make it a priority to ensure that it treats families and patients with respect and is honest and open with them.

Andrea Sutcliffe CBE, NMC Chief Executive and Registrar, 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.

“This investigation highlights a number of failings at the NMC at that time. We did not properly understand the significance of this important piece of evidence, in particular to Mr Titcombe and his family, and we did not put it before the panel when we should have done. This 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.

“Since the events at Morecambe Bay we have made significant changes, including much improved record keeping, the introduction of a new public support service, and additional training for panel members to help them better understand the needs of witnesses.

“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.

“The complexity of our processes and the time taken to resolve issues remain challenges for the NMC and other regulators. This has an impact on people affected by poor care and the registrants under scrutiny. We will continue to work hard to refine and implement our new approach to fitness to practise that ensures people are at the heart of everything we do and helps us to protect the public in a fair, effective, proportionate and consistent way.

“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.”

We provided the report to Mr Titcombe who has shared his views with us and agreed to include them in this statement.

Mr Titcombe said:

“I am grateful to Andrea for her frank and open acknowledgement that the way my family and I were treated by the NMC in 2016 and subsequently was not acceptable.

“I do not believe that any bereaved family should be subjected to the distressing treatment and process we faced, made all the more worse by the untrue and misleading explanations given when I raised concerns about what happened at the hearings with the former Chief Executive of the NMC afterwards. I knew that the excuses given at the time made no sense, but the fact that it took an external investigation by the PSA before we were told the truth, is something that still shocks me.

“I am very encouraged that the NMC are now taking positive steps to make the fitness to practice process a kinder and more human process for everyone involved and I do believe that under new leadership, the culture at the NMC is changing in the right direction. Whilst I welcome the steps that are now being taken, I do not believe that the Verita report has satisfactorily explained how the untrue and misleading account of what happened came to be given to so many people.”

Download Verita's independent audit to review the NMC’s handling of documentation relating to midwives at Furness General Hospital.


Further background

The total cost of Verita’s report was £151,742.22.

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