Toni MartinLSA 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

OutcomeNo further action

Training needs identified Disciplinary procedures begun

Dismissal from TrustReferral to NMC

Clinical Risk Investigation

Management tool

Supervisory Investigation

No further actionLocal Action

Developmental SupportSupervised practice

Refer to NMCLSA 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 out

whatwhy 60% of time spent should

be fact finding

how

Gather information◦ Maternal notes◦ Relevant policies & guidelines◦ Gather statements if you feel it is relevant◦ Staff rotas◦ Training records◦ Equipment involved

Interview◦ 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 1I 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

Panel Member

Legal assessor

Case presenter

Registrant Legal Representative

Observers/Past witnesses Press

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?