PASC follow up Parliamentary and Health Service Ombudsman’s reports on severe sepsis and midwifery supervision and regulation

PHSO, Daniel Poulter, NICE, David Haslam

The Public Administration Select Committee (PASC) takes evidence from two panels of healthcare experts in a one-off evidence session following up the Parliamentary and Health Service Ombudsman’s reports into severe sepsis and midwifery supervision and regulation on Wednesday 10 September at 9.30am.

Health Minister Dr Daniel Poulter MP, NICE chair Professor David Haslam, UK Sepsis Trust Chair Ron Daniels, and NHS England’s Director for Patient Safety, Dr Mike Durkin, will give evidence to the Committee on the conclusions and recommendations of the Ombudsman’s report into severe sepsis.

Joining Health Minister Dr Poulter to give evidence on the Ombudsman’s report on midwifery supervision and regulation is a panel of experts comprising Jackie Smith, Chief Executive of the Nursing and Midwifery Council; Juliet Beal, Director of Nursing for Quality Improvement and Care, NHS England; Richard Murray, Director of Policy at the Kings Fund; and Elizabeth Duff, Senior Policy Adviser at NCT.

Particular issues to be explored in this evidence session may include

Sepsis

To what extent the Ombudsman’s recommendations in Time to Act Severe Sepsis: rapid diagnosis and treatment saves lives have been implemented.
The adequacy of progress made to date.

Midwifery supervision and regulation

To what extent the Ombudsman’s recommendations in Midwifery supervision and regulation: recommendations for change have been implemented.
The adequacy of progress made to date.

Parliamentary and Health Service Ombudsman (PHSO): PASC’s scrutiny role

The Parliamentary and Health Service Ombudsman is an independent organisation set up by Parliament almost 50 years ago and sits at the apex of the complaints system. PHSO investigates complaints where individuals have been treated unfairly or have received poor service from government departments, other public organisations and the NHS in England. The service that PHSO provides is governed by law, free to use, open to everyone and completely independent.

The Public Administration Select Committee scrutinises the reports of the Parliamentary and Health Service Ombudsman. PASC monitors complaints about the Ombudsman as a way of examining the work of her office and identifying systemic problems, but does not consider individual cases.

PHSO’s report Time to Act Severe Sepsis: rapid diagnosis and treatment saves lives

Sepsis is a very common bacterial or fungal infection, and usually responsive to antibiotics, but in a small proportion of cases infection can overcome the body’s immune system and progress rapidly to critical illness – known as severe sepsis. Sepsis is a time-critical condition that can lead to organ damage, multi-organ failure, septic shock and eventually death. Although most dangerous in those with impaired immune systems, it can be a cause of death in young and otherwise healthy people.

In September 2013, the PHSO published Time to Act Severe Sepsis: rapid diagnosis and treatment saves lives. The report highlighted 10 cases where people with severe sepsis did not receive the urgent treatment they needed and died. The case examples include failings in the care and treatment of people with severe sepsis at home, in hospital emergency departments and in hospital wards.

PHSO’s report on Midwifery supervision and regulation: recommendations for change

PHSO published a thematic report on midwifery regulation – Midwifery supervision and regulation: recommendations for change in December 2013. This followed PHSO investigations into complaints from families at Morecambe Bay NHS Foundation Trust. In all three cases, the local midwifery supervision and regulatory arrangements failed to identify poor midwifery practice. While the Ombudsman found no direct evidence of a conflict of interest in these cases, they illuminated a potential muddling of the supervisory and regulatory roles of Supervisors of Midwives (Supervisors). The report concluded that this means there is a risk that midwives fail to learn from mistakes, putting the safety of mothers and babies at risk.

Following the Ombudsman’s report, the Nursing and Midwifery Council (NMC) acknowledged ‘a structural flaw in the framework for midwifery regulation’. The NMC commissioned the King’s Fund to undertake an independent review of midwifery regulation, which aims to report in January 2015. The PHSO has made a written submission to the review.