Toni Martin
LSA Project Midwife






How to investigate an area of concern in
midwifery practice
Preparing for and conducting an investigatory
interview
Summing up your findings for the report
Making recommendations to the LSA
Creating supervised practice programme
objectives
A trip to the NMC

Quick Quiz


NMC Order
The Nursing and Midwifery Order (2001)
requires the Nursing and Midwifery council
(NMC) to set rules and standards (Midwives
rules and standards 2004) for the function of
statutory supervision of midwives


Outlines responsibilities of the LSA, SOM and midwife
Rule 5 - Guidance
◦ ‘If you are concerned about a midwife’s ability to practise safely
and effectively you must report this to a supervisor of midwives,
who will liaise closely with the LSA Midwifery Officer. Service
users, colleagues or managers may also voice such concerns. This
will identify those midwives who need additional support,
supervised practice or on rare occasions, need to be suspended
from practice in the interests of their or public safety.’
◦ Rule 15 - The standard outlines need for LSA to be informed of
the outcome of any LSA investigation of poor practice

Section 5
(2) -
Competencies for a SOM
◦ Understand the supervisor’s role in the investigatory
process by demonstrating ability to:
◦ undertake an investigation of any serious untoward
incident concerning midwifery practice or of an
individual midwife’s alleged impairment to practise
◦ prepare a supervisory report of the investigation’s
outcomes and recommendations and inform the
LSAMO
◦ in cases where supervised practice is recommended,
set agreed learning objectives for the midwife, with a
midwifery educationalist, and monitor progress
support a midwife involved in the investigatory process
NMC Circular 32/2007 Annexe 1
 Local Supervising Authorities appoint supervisors
of midwives to monitor, on behalf of the authority,
the practice of midwives against standards set by
the NMC with the aim of ensuring safe practice for
protection of the public.
Standard 1 - Investigation of alleged lack of competence
1.1 Following an untoward event or the recognition of circumstances indicating lack of
competence, a Supervisor of Midwives, independent of any management
investigation, should undertake a full supervisory investigation of untoward incidents
or circumstances. This should include where necessary a risk analysis and root cause
analysis.

1.2 Supervisory investigations should take place as soon as possible after any untoward
event or circumstances, and may be initiated by a Supervisor of Midwives regardless
of any employment processes. The Local Supervising Authority should be informed
that a supervisory investigation has commenced.
1.3 The named Supervisor of Midwives should provide supervision support to the
midwife and not normally be involved in conducting the investigation.
1.4 The supervisory investigation must be open, transparent and fair and must provide
opportunity for the midwife to be involved and present her side of events. Midwives
have a responsibility to co-operate with supervisory investigations.
1.5 Supervisory records must be made of the investigation including
signed statements from any participants. These documents are
confidential to the LSA and are not disclosable to employers or to
other investigating authorities without a court order.
1.6 The supervisory records should be stored in accordance with NMC
requirements for retention of supervisory records.
1.7 The investigation report should include a summary and conclusion
of the investigation and what recommendations are made to the
Local Supervising Authority for future action.
1.8 If the investigation identifies that system failures have contributed
to unsafe practice this must be reported to the Local Supervising
Authority and to the Director of Midwifery or equivalent manager of
the maternity service.




Complaint(s) from parents
Clinical incident(s)
Serious untoward incident
General concerns raised about ability to practise
safely and effectively (must be evidenced)






Low standard of work, for example, frequent mistakes,
not following a task through, inability to cope with
instructions given
An inability to handle a reasonable volume of work to a
required standard
Unacceptable attitudes to work of colleagues, for
example, unco-operative behaviour, poor
communication, inability to acknowledge the contribution
of others poor team work, lack of commitment or drive
Poor punctuality and unexplained absences
Lack of skills in tasks/methods of work required
Lack of awareness of required standards
Clinical incident
Managerial
Investigation
Outcome
No further action
Training needs identified
Disciplinary procedures begun
Dismissal from Trust
Referral to NMC
Clinical Risk
Investigation
Management tool
Supervisory
Investigation
No further action
Local Action
Developmental Support
Supervised practice
Refer to NMC
LSA Suspension from practice

The Incident





Monday am, notified of a neonatal death
following transfer in from home (booked for
home birth)
Transferred in as undiagnosed breech and fetal
heart decelerations at home
The consultant suggests that the fetal heart was
not adequately monitored
Midwives very distressed, parents inconsolable
What will you do?








Look at notes
Identify immediate areas of concern
Talk to midwife
Have rules or code been breached?
Is there evidence of misconduct or lack of competence?
Do you have time to wait for RCA?
Consider where midwife should now work
Make decision about supervisory investigation and notify
LSA








Decided to investigate?
Now what?
What is the process?
Who do you involve?
How do you tell the midwife?
How can you prepare?
What resources do you have?
What happens in a joint investigation?




Start a diary of events – (save copies of everything)
Inform midwife - in writing
◦ Who you are
◦ What you are doing
◦ Which supervisor the midwife to go to for support
◦ Confidentiality of investigation
◦ Why you are doing this
◦ What will happen in the investigation process
◦ When do you hope to complete this
◦ How will midwife (s) be involved – will be invited to be
interviewed and will be able to bring someone as support
(union rep, SoM, friend or colleague)
◦ What happens at the end of the process - outcomes
Inform manager if employed - meeting
◦ Check to see if clinical risk or managerial investigation is going to
take place
Negotiate time out from clinical duties to ensure timely investigation
 Finding
what
why
how
out
60% of time spent should
be fact finding

Gather information

Interview
◦
◦
◦
◦
◦
◦
Maternal notes
Relevant policies & guidelines
Gather statements if you feel it is relevant
Staff rotas
Training records
Equipment involved
◦ Everyone that had involvement in the case or collect
statements
◦ The mother (and partner) if you feel it is appropriate
Issue to be explored = You in your investigation
consider that the midwife failed to monitor fetal
and maternal wellbeing adequately
Consider - would I expect a midwife to be able to
monitor fetal and maternal wellbeing and act upon
it

The Interview






How do you prepare?
What resources do you need?
Worries, fears, concerns
Who should be present?
What questions should you ask?
2/3 questions from each table, 2 of you will be
interviewing the midwife following this exercise




This is the midwife’s opportunity to explain his or her actions
A record of the interview should be maintained with a witness
present (e.g. another SoM). Take time to take accurate notes. Pause
the interview so that you have time to take notes.
Support for the midwife
Questions you may have
◦ Did the midwife have






A thorough induction to work area
Training and supervision where necessary
Preceptorship and mentoring
Ongoing access to professional development
Clinical supervision
Supervisory annual review

Use cognitive questioning approach
◦ Open questions
◦ Recreate context of the original event
◦ Pauses (allow pauses of longer than 7 seconds)
◦ Be clear
◦ Set parameters
◦ Tell everything – once parameters are set ask them to
talk about the events as they remember them using
the case notes as a prompt
◦ Relax the individual
◦ Firm but fair – repeat questions that are not answered
or if the point has been missed




Ask her to give her account of what happened, her actions and her reason
for those actions
Ask how did she feel
Go through each area where you allege that she failed/omitted to act and
thus breached the rule or code of conduct and listen to responses
Ask about any mitigating circumstances
◦
◦
◦
◦


Absence of recognised supervision
Ill health affecting the midwife’s judgement, behaviour of intellectual function
Denial of access to training opportunities
System failures
End the interview by stating that you will have to review all the information
available to you before you can make a recommendation for the next
course of action
You can state what the possible outcomes are

Writing the Report







Contents page
Section 1 – Summary of concern/incident
Section 2 – Midwife personal details
Section 3 – Chronology, supervisory action
and events summary
Section 4 – Supervisory investigation
report
Section 5 - Recommendation to NMC
Section 6 - Supporting evidence
documents
Failure 1
I allege that MW Smith failed to provide an appropriate
standard of care in labour by not adequately monitoring
maternal well being.
 Alleged breach of Midwives Rules – Rule 6
◦
The registrant did not monitor Mrs A’s temperature, pulse or blood pressure hourly once labour had established.
Evidence



Within the notes the maternal observations were recorded once at
01.55. There is no evidence that they were recorded again (Labour
notes App 1)
MW Smith’s statement of June 20th says that she did undertake
further observations but did not record them (Statement App 2)
MW Smith reiterates the above in her interview of 23 June and that
her usual practice is to take and record maternal observations
according to trust guidelines (Interview notes App 3)


An audit of MW Smiths records from 10 other cases shows that her
usual practice appears to be to record maternal observations
according to trust policy (Records audit summary App 4)
Mr & Mrs A do not recall maternal observations being taken during
labour (Notes from discussion App 5)



Mitigation
Midwife’s previous records (Has this midwife had
supervised practice before for the same issues –
developmental support)
Recommendation to the LSA
◦
◦
◦
◦
◦
No further action/local action
A period of developmental support
A programme of supervised practice
Refer to NMC
LSA investigation and suspension

Supervised Practice






Investigation of alleged lack of Competence
Criteria for use of Supervised Practice
Decision for Supervised Practice
Structure for Supervised Practice
Monitoring of Supervised Practice
Follow-up of Supervised Practice


Supervised Practice should be
used when there are serious
concerns about the midwives
attitude or the safety of their
practice. It provides an
opportunity to address identified
shortcomings in practice and to
assess formally a midwife’s
competence to remain on the
NMC Register
It should not be used for
minor, non recurring mistakes
which can be corrected through
developmental support





The LSA will ensure the investigation has met the NMC
requirements.
Ensure a health assessment of the midwife has been
carried out
If Supervised Practice is required, the midwife should
not practise within another LSA until such time as the
supervised practice has been completed
If supervised practice is not commenced, not completed
or failed in meeting its objectives, the LSA Midwifery
Officer must refer the midwife to the NMC
The midwife may complain to the LSA about the process
but this will not delay or interfere with any
recommendations made.








Joint plan between Investigating SoM, Midwife,
Educational Lead, Head of Midwifery & supported by
Named Supervisor
Advised and approved by LSAMO
Programme of Objectives and Learning Outcomes
specific to the incident(s)
No less than 150 and up to 450 hours with extension
with LSA approval of 150hours
Aim to be completed in 6 months
Midwife must be supernumerary to the rota
Supported by a ‘sign-off’ mentor
Cannot be involved with the teaching of students





Objectives – Must be
measurable, derived from
the incident findings,
achievable, realistic, clear
Programme planning vital
Mentors – sign off
Support – named SOM,
HOM
Meetings and recording
progress



















Contents page
Supervised practice programme
Recommendation for supervised practice
Criteria for use for supervised practice
The aim of the programme
Overall objectives of this supervised practice programme
Recommendation to the LSA
Check list prior to commencement of the programme
Health assessment
Employment issues
Unsuccessful or incomplete programme
The role of those involved in this supervised practice programme
Time plan for programme
Meetings
1. Planning and initial programme meeting
2. Interim programme review meeting
3. Final programme review meeting
Supervised practice learning contract
Learning Objectives for programme


Objective one Competency - Demonstrate
the ability to practice safely and effectively
whilst undertaking a supervised practice
programme aiming towards safe and
autonomous practice
Objective two Competency – Practice in
accordance with the NMC codes, standards and
guidelines. Understands the local and national
political agendas that impact on Midwifery
practice including local Trust guidelines and
policies


Objective three Competency – Maintain
accurate, relevant, concise and contemporaneous
hand written and/or electronic records as
appropriate.
Objective four Competency – Able to monitor
fetal wellbeing in labour with particular reference
to recognition of abnormalities and taking
appropriate action.




The midwife, her ‘sign-off’ mentor, the midwife teacher and Named
Supervisor of Midwives should meet at indicated intervals with the
Investigating Supervisor (and the Head of Midwifery) to consider
progress
Records of completion or failing of the programme will be kept by
the ‘sign-off’ mentor and retained in the midwives supervisory file
and sent on to the LSA
Throughout any supervised practice programme a midwife remains
accountable for her actions. Any further incidents of unsafe practice
during this period should be communicated to the LSAMO.
It may be agreed that new learning outcomes be accommodated or
if considered seriously enough, the programme may be terminated
and the LSAMO refer the midwife on to the NMC.




A programme of continued support should be put in place for those
midwives who have successfully completed a Supervised Practice
Programme
If the Supervised Practice Programme is failed, the midwife will be
Suspended from Practice by the LSA and referred on to the NMC
The midwife is normally required to share information about
programmes of supervised practice with future employers and
Named Supervisors of Midwives
There is no limit indicated as to the number of Supervised Practice
Programmes a midwife can successfully complete prior to referral to
the NMC. This is left to the discretion of the LSA!








Poor health that renders the midwife until to practise
safely
Misconduct (Verbal or Physical abuse, theft, deliberate
failure to care or keep adequate records)
Intractable lack of competence
Failure to undertake or successfully complete a
programme of Supervised Practice
Convictions or Cautions
Referral from another regulator (NPSA or other
professional register)
If referred, clear evidence of Investigation and
Supervised Practice processes must be provided to the
NMC
The NMC may refer back for further LSA actions if these
are deemed inadequate

Unlikely to accept referrals from employers without evidence of LSA
processes.

Will ask the LSA to investigate for parents or families who direct
initial complaints to the NMC



Will accept referrals from the LSA where the LSA have investigated
and have proceeded to Suspend from Practice despite not
completing any Supervised Practice Programme if this is not
recommended
Will reverse Suspensions from Practice if there is no evidence of an
LSA investigation that meets the NMC standards
Will not accept referrals from employers where the midwife has
been dismissed without evidence of LSA processes unless for
misconduct




If it is alleged that if a nurse or midwife is guilty
of lack of competence the employer should have
tried to address these issues.
For example it is unlikely that if you made a one
off mistake you would be referred to the NMC
The employer/LSA would identify any learning
needs and set out a plan of training.
If a registrant continued to show lack of
competence despite training opportunities or
failed to engage in training they would be
referred to FTP.



Those registrants with health issues would be
referred to a special health committee with
medical practitioners on the panel to offer
expert opinion.
These may be held in private due to the
sensitive information although the outcome
would be made public.
Mainly related to drug, alcohol issues or
untreated serious mental illness.




Most cases of alleged impairment are referred
by employers and the police.
However, anyone can refer an allegation to the
NMC.
Referrers should first have their concerns
investigated at the local level.
Referrals concerning midwives should always be
considered first by the local supervising
authority midwifery officer


If not resolved at a local level then full details
of the investigation along with statements are
sent to the NMC
This is then reviewed by the Investigating
Committee who can -
◦ close the case with no further action taken
◦ refer the case to a panel of the Conduct
Competence Committee (CCC) in cases about
alleged impairment of fitness to practise
◦ for reasons of ill health, refer the case to a panel of
the Health Committee (HC)


The Investigating Committee can also place an
interim suspension or conditions of practice order
on the registrant.
This would be done to protect the public whilst
awaiting the substantive hearing.


CCC hearings are generally held in public; the
openness of the proceedings reflects the NMC's
public accountability
The CCC consists of a panel of at least three
people, lay panel member, due regard (on same
part of register as registrant) plus one other
Panel
Member
Council
Officer
Legal
assessor
Panel
Member
Case
presenter
Observers/Past
witnesses
Press
Registrant
Legal
Representative

The panel will decide whether a registrant’s fitness
to practise is impaired by reason of:
◦
◦
◦
◦
Misconduct
Lack of competence
A criminal offence
Mental or physical health



Whilst making decisions (CCC) panels look for
the level of conduct and competence expected
of the average registrant, not for the highest
possible level of practice.
They base all decisions on evidence heard at
the hearing and see no papers in advance of
the case.
Before the panel makes a final decision they
hear information about the previous history of
the registrant and any evidence in mitigation
from the practitioner


Used to be the criminal standard of proof (beyond
reasonable doubt) but not suitable as FTP is not a
criminal court
As from November 2008 changed to civil standard
–
‘balance of probabilities’
◦ That is a fact will be established if it is more likely than
not to have happened






Conclude that the case is not well founded and
therefore take no further action
Decide, taking into account all the circumstances of
the case, it is not appropriate to take further action
Issue a caution for a specified period of between one
and five years
Impose a conditions of practice for a specified period not
to exceed three years
Suspend the practitioner's registration for a specified
period not to exceed one year
Strike off the practitioner’s name from the register








667,072 registrants (March 2010)
Referrals in 2010/11 - 4,211 (2,215 sent for investigation)
This represents 0.6% of registrants
41% referred from employers
23% from police
23% from the public (16% in 2009/10)
13% other referrals
2% from other health professionals








647 cases referred to Conduct & Competence Committee
246 hearings
Striking off order – 187 (76% of above number of hearings) 0.02% of
total register
Caution order 100(40%)
Conditions of practice order – 39 (15%)
Suspension – 89 (36%)
Fitness to practise not impaired - 76 (30%)
Restoration to register - 4 (6%)
Please read NMC Annual Fitness to Practise Report 2010-11 for more
details on all of this information













Dishonesty – 25%
Patient abuse/inapp relationship – 22%
Lack of competence – 24%
Failure to maintain adequate records – 4%
Other practice related issues (unsafe)– 7%
Drugs (mal-admin/theft) - 2%
Management practices -2%
Failure to collaborate with colleagues/abuse –3%
Accessing porn- 4%
Violence – 4%
Serious motoring offences – 2%
Substance misuse – 3%
Other (convictions)– 5%




Ensure that documentation is clear and logical –
pages numbers etc.
Accurate evidence, signed by registrant etc
Ensure that standards are followed- if system
falls down anywhere it is likely that the panel
will notice. It is better to address this at the time
than the case be affected.
Examples include limited experience due to quiet
clinical area, poor supervision, lack of sensitivity
towards supervised midwife, no orientation
period in new area.

Academic work- ensure midwife knows how it will be
marked, to what level required, that they are able to
update study skills, given feedback.

Keep records of ALL communication

Being a witness – behaviour, no collaboration, read
statement, be prepared to be contradicted.

Time management at hearings

Media attention
(1)
Failed adequately
(a)
to monitor;
(b)
to safeguard
the fetal well-being of Patient A;
(2) Failed adequately to assess
(a)
the condition of Patient A;
(b)
the progress of Patient A's labour;
(3) Failed to communicate effectively with Patient A;
(4) Failed to take appropriate action where the
progress of Patient A's labour fell outside normal
parameters in that you:
(a)
failed to consider all possible causes of
fetal tachycardia at 04.00 hours and
04.30 hours, 05.30 hours, 05.55 and
(b)
went for a walk at 04.30 leaving Patient A
unattended;
(c)
delayed attempting to carry out vaginal
examination until 05.30 hours;
(d)
allowed Patient A to get into her birthing
pool at around 06.05 hours and remain in the
pool until approximately 06.15 hours;
(e)
did not take steps to transfer Patient A to
an obstetrics unit until 06.15 hours;
(f)
allowed Patient A to wait unaccompanied in
her garden while an ambulance was awaited;
(5) Failed to maintain an adequate record of the care
delivered to Patient A.

Your decision if you were on the panel?

Any questions?