Midwifery lecturer Sarah Davies reports on the NMC’s case against Debs Purdue

Davies, SE

English

University of Salford Institutional Repository

Debs Purdue: Independent Midwife with 25 yearsexperience - struck off the register by The Nursingand Midwifery Council.‘She is an experienced midwife with good knowledge, skillsand competence. She has a totally unblemished record’ -the words of the Local Supervising Authority Midwifer yOfficer (LSAMO) in her repor t at the conclusion of asupervisory investigation (March 2006) of Debs Purdue’spractice following one bir th in July 2005 where the baby,having been born in hospital under medical care, diedshor tly after bir th.The supervisory repor t was sent to the Nursing andMidwifer y Council (NMC) in May 2006. Debs was notsuspended from practice, and continued to work as amidwife, both in hospital and independently, for the nextthree and 3/4 years. On 20th March 2009, following aFitness to Practice hearing, the NMC issued a striking offorder - to protect the public.Midwifery supervisionSupervision is required by British law, and its purpose is‘to protect women and babies by actively promoting a safestandard of midwifer y practice.’1 Every midwife has aSupervisor of Midwives (SoM) with whom she has anannual review, where her practice is reviewed and anyeducational needs identified. Supervision of midwives hasa very impor tant role to play when there is an adverseoutcome; investigating and putting safeguards in place ifpoor practice is identified; encouraging the midwife toreflect on her care and learn from the experience;suppor ting the midwife so that she can continue topractice safely and competently, and often, suppor ting thebereaved parents.Local supervisory processes in Debs’ caseSix days after the death of the baby, on 25th July 2005,Debs and the second midwife, her independent midwifepar tner, were invited to a meeting. This subsequentlyproved to be, rather than the suppor tive debriefingmeeting that the midwives expected, the first step ofevidence-collecting in a supervisory investigation. TheNMC2 (page 5) states ‘midwives under investigation […]should be informed about the super visor y investigationbefore it commences.’ Debs’ own SoM wrote a formalcomplaint on 2nd September pointing out that theprocess so far had breached the provisions outlined inthe Standards and Guidance for Supervisors of Midwives.Her complaint was upheld by the LSAMO, who wrote on22nd September :‘As you are already aware I share your concerns (…) I willgo through the issues with both super visors - it has certainlymade me think about providing specific training aroundinvestigation for super visors in the future.’The initial meeting having been discounted, a newinvestigation was instigated, led by a different SoM, whowrote a repor t on 6th October 2005. There followedthree months of emails between Debs and the LSAMO,followed by a meeting on 5th January 2006 to gatherfur ther evidence regarding Debs and her par tner IM’scareer history, cases attended and to review previouscase notes.Referral to the NMCOn the 20 March 2006, nine months after the death ofthe baby, Debs had a meeting with the LSAMO. She wastold the LSA investigation was now complete, and thatshe was being referred to the NMC. In her repor t to theNMC (sent over two months later) the LSAMO says thatshe had ‘been advised’ to refer the case to the NMC.There is no indication in the letter as to the source of the‘advice’. In the letter to Debs informing her of herreferral, there are sections of the Midwives Rules3 quotedunder the heading ‘Breach of Midwives Rules andStandards’ but no specific allegations. The letterconcludes with the statement that the LSAMO does notintend to suspend Debs from practice.The LSAMO’s decision not to suspend Debs at thispoint indicates that she did not feel that Debs constituteda danger to the public. There had been one adverseoutcome in 25 years and in the words of the sameLSAMO in the same repor t to the NMC: ‘She is anexperienced midwife with good knowledge, skills andcompetence. She has a totally unblemished record.’Referral to the NMC is a serious event, usually relatedto continuing lack of competence despite supervisedpractice, where ‘over a prolonged period of time aregistrant makes continuing errors or demonstrates poorpractice’3 or because of ‘ser ious professional misconduct.’The NMC2 (page 3) cites the most common examples as:• Physical or verbal abuse• Theft• Deliberate failure to deliver adequate care• Deliberate failure to keep proper recordsThere were no such issues in Debs’ practice.LSA Guidance, South of England4 on page 5, section 5states: ‘The NMC will not normally become involved in acase if it is not demonstrated that considerable measureshave already been taken to tackle the situation at aworkplace level (…) the NMC’s role is to protect the publicfrom registrants whose fitness to practice and whosesituation cannot be managed locally. (…) Reporting a caseof unfitness to practice to the NMC is appropriate to theextent that public protection may be compromised.’AIMS JOURNAL VOL:21 NO:3 2009 9Jury of your peers?Midwifery lecturer Sarah Davies reports on the NMC’s case against Debs Purdueone adverse outcomein 25 yearsThe question must be asked: why was a midwife with an‘unblemished record’, and no period of supervised practice,referred to the NMC by the LSAMO in the first place?Different treatment for independent midwives?The LSAMO’s repor t continues: ‘the situation has beenmade more complex by the fact that the midwives areindependent practitioners. I have grappled with therealisation that if the practitioners were employed within aTrust then they may have been advised to undergosupported or super vised practice and/or disciplinar y action.’The same repor t, however, recommends that the secondmidwife in the case, also an independent midwife, ‘isplaced on a formal programme of super vised practice inaccordance with the LSA guidance.’The repor t adds: ‘It seems particular ly harsh that as a tierof punitive/remedial action is missing (by the ver y fact thatthey (sic) are independent) that they (sic) now face referralto the regulator y body.’ (The second midwife organisedher own supervised practice and completed it withassistance from the Trust nearest to her home).The NMC Fitness to Practice process: inefficient andunaccountableOn the 30th May 2006, Debs’ case was referred to theNMC. On 24th October 2006, almost five months later,the first investigating committee (IC) met. There werefour fur ther ICs held and the NMC heard the case on 3rdto 7th November 2008. Evidence from the initial,discounted meeting was requested - this would beinadmissible in a cour t of law and so was sucessfullychallenged. Proceedings were subsequently adjourneduntil March 16th 2009. The panel decided against passingan interim suspension order, justifying its decision withthe words : ‘Amongst the factors we bear in mind are (1)the amount of time that has elapsed since the allegationand (2) the fact that there is a degree of super vision inplace to protect the public .’ Therefore the Council decidedin October 2008 that Debs could continue to practiceand was not, by implication, a danger to the public. Shehad been practising as a midwife for the whole course ofthe investigation, since July 2005, and continued to do sountil March 2009, when the Conduct and CompetenceCommittee (CCC) reached its final decision.The CCC first considered various sanctions:1) No action: decided against, as ‘facts too serious’2) Caution: decided against, as ‘facts too serious’3) Conditions of practice order : decided against, as ‘thepanel was satisfied that there was no practical method ofimplementing the sanction’ due to the fact that she wasself employed; however, a 'conditions of practice order'had been applied in a ear lier case involving anindependent midwife.4) Suspension order : decided against, as ‘misconductwas so serious that it was not appropriate or in the publicinterest to do so.’ Therefore Debs was struck off theregister.Serious misconduct?Debs was found guilty of:1) Failure to carr y out proper fetal hear t (FH) rateauscultation2) Failure to conduct an ear ly vaginal examination3) Allowing ‘Patient A’ to get into the bir thing poolafter there had been several readings of the fetal hear trate outside normal parameters.The CCC panel consisted of: two lay people, a barristerand a retired hospital administrator with no knowledge ofmidwifer y (cour t transcripts). The other was a midwife,with nine years experience; a labour ward manager in aconsultant obstetric unit. Because he was the only panelmember with midwifer y experience, his opinions wentunchallenged. If the NMC hearing had been a cour t oflaw, exper t witnesses would have pointed out:In relation to finding 1) The NICE guidelines5 (thepanel’s standard for ‘proper’ FH monitoring) areguidelines not rules. The NICE guideline on timing ofauscultation of the FH is not evidence based. There wasconfusion during the hearing because the guidelines werechanged between the indident and the hearing.In relation to finding 2) Many exper t midwives wouldnot conduct an ear ly VE when the labour appeared to benormal. There are other less intrusive ways to assesslabour, including maternal observation and abdominalpalpation.In relation to finding 3) ‘Allowing “Patient A” to get intothe pool’: the language used gives some indication of themindset of the panel.In conclusion:• The only midwife on the panel came from a hospitalbackground: his perspective is not shared by midwiveswho have extensive experience of out-of-hospital bir th.• The panel were indeed in a position to imposeconditions of practice if they had judged this necessar y.• Debs practised safely for near ly four years duringthis process. Both the LSAMO and the NMC judged thatshe was not a danger to the public during this time.This sad case brings into question the constitution ofthe NMC and its competence to protect the public.Moreover, the lengthy and inefficient process whichculminated in the striking off order, and the consequentstress and suffering inevitably endured by the practitioner,cannot be ethically defensible.Sarah DaviesSenior Lecturer in Midwifery,University of SalfordThanks to Dr Brenda Ashcroft for reading and commentingon a draft of this paperReferences1. NMC and LSAMOs National (UK) Forum (2008)Modern Supervision in Action- a practical guide formidwives. London.2. NMC (2007) Standards for the supervised practice ofmidwives http://www.midwife.org.uk Accessed 7/11/093. NMC (2004) Midwives’ Rules and Standards. London4. Standards and Guidance for SoMs in the South ofEngland. April 2004. Now in 3rd edition 2008; availableonline at www.southcentral.nhs.uk5. NICE (2007) Intrapar tum care: care of healthy womenand their babies during childbir th. www.nice.org.uk/nicemedia /pdf/CG55FullGuideline.pdf Accessed 8/11/0910 AIMS JOURNAL VOL:21 NO:3 2009

Jury of your peers?

Guidance for SoMs in the South of England.

Intrapar tum care: care of healthy women and their babies during childbir th.

Intrapartum care: care of healthy women and their babies during childbirth.

LSAMOs National (UK) Forum

Midwives’ Rules and Standards. London

Standards for the supervised practice of midwives http://www.midwife.org.uk Accessed 7/11/09

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Jury of your peers?

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