Orlando Davis

Dear Ms Schofield

Private and confidential

The late Orlando Davis – NMC response to Regulation 28 Prevention of Future Deaths report

Thank you for sending your Regulation 28 Prevention of Future Deaths (PFD) report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 to us for review. I write to provide a response on behalf of the Nursing and Midwifery Council (NMC).

I’d like to begin by offering my sincere condolences to Master Orlando Davis’s family for their great loss. I’d also like to assure you and them that I take the concerns you have raised in the Regulation 28 PFD report very seriously. I set out below the steps we will take to respond to the concerns raised. In summary:

1. We are carrying out Fitness to Practise (FtP) investigations and will take appropriate action to protect the public and uphold standards where we identify concerns relating to professionals on our register.

2. We have shared the PFD report with the General Medical Council (GMC) so they can take appropriate action which falls within their remit.

3. We will develop and publish a scenario to inform student midwives and midwives about hyponatraemia for the start of the next academic year and raise awareness with our education colleagues.

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Background

I note that your investigation into Orlando’s death concluded that there had been a complete lack of awareness or understanding of hyponatraemia by those who cared for Mrs Davis (Orlando’s mother) when she suffered a seizure during labour. You indicated that it is that lack of understanding which led to Mrs Davis being encouraged to take in more fluid during labour, ultimately causing Orlando to develop a tachycardia as there was no recognition by the midwives or the doctor on duty of the potential risk of hyponatraemia developing; and lastly but not least, the failure to keep accurate records of either input or output of fluid.

As a result, you have raised the following concerns:

1. The concern that midwives (in the community and in the hospital) were completely unaware of this potential condition developing in birthing women.

2. No accurate records were kept of either input or output fluid and there was no recognition of any potential risk of hyponatraemia developing by the midwives or the doctor on duty.

Our function

The NMC is the independent regulator of more than 808,000 nurses and midwives in the UK and nursing associates in England. We’re here to protect the public by upholding high professional nursing and midwifery standards, which the public has a right to expect. We’re continuing to improve the way we regulate, enhancing our support for colleagues, professionals, and the public, and working with our partners to influence the future of health and social care.

The over-arching objective of the NMC in exercising its functions "is the protection of the public" (Article 3(4) of the Order) and Article 3(4A) provides that:

"The pursuit by the Council of its over-arching objective involves the pursuit of the following objectives:

(a) to protect, promote and maintain the health, safety and wellbeing of the public;

(b) to promote and maintain public confidence in the professions regulated under this Order; and

(c) to promote and maintain proper professional standards and conduct for members of those professions."

Our core role is to regulate. We set and promote high education and professional standards for nurses and midwives across the UK, and nursing associates in England and quality assure their education programmes. We maintain the integrity of the

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register of those eligible to practise. And we investigate concerns about professionals
– something that affects very few people on our register every year.

To regulate well, we support nursing and midwifery professionals and the public. We create resources and guidance that are useful throughout professionals’ careers, helping them to deliver our standards in practice and address challenges they face. We work collaboratively so everyone feels engaged and empowered to shape our work.

We work with our partners to address common concerns, share our data, insight, and learning, to influence and inform decision-making and help drive improvement in health and social care for people and communities.

It falls within our remit to take appropriate steps to ensure that registered midwives have the skills and knowledge they need to deliver safe, kind, and effective midwifery care for women giving birth and newborn infants. I have explained in further detail below how our standards and processes apply in relation to the concerns you have raised.

Standards for Midwives

Our standards of proficiency apply to all NMC midwives. They should be read with our standards for education and training, which set out our expectations regarding provision of all pre-registration and post-registration NMC approved midwifery education programmes. These standards apply to all approved education providers and are set out in three parts including the standards framework for nursing and midwifery education, the standards for student supervision and assessment, and the programme standards, which are the standards specific for each pre-registration or post-registration programme.

Midwifery students are assessed to ensure they are proficient in providing safe, effective, and kind care that improves the health and wellbeing of the women and newborn infants in their care. Proficiencies are the knowledge, skills, and behaviours that midwives need to join our register and practise.

We do not specify a list of diseases or conditions that professionals need to know or be able to provide care in respect of. This is because it would not be possible to keep such a list up to date and complete. We rely on our Approved Education Institutions (AEIs) to develop evidence-based curricula which reflect local practice contexts and the population.

I set out below the relevant sections within the domains of the Standards of proficiency for midwives that are most relevant to this case.

Under Domain 1, midwives are required to understand and apply the principles of courage, integrity, transparency, and the professional duty of candour, recognising

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and reporting any situations, behaviours, or errors that could result in sub-standard care, dysfunctional attitudes and behaviour, ineffective team working, or adverse outcomes. Midwives are also required to understand the importance of effective record keeping, and maintain consistent, complete, clear, accurate, secure, and timely records to ensure an account of all care given is available for review by the woman and by all professionals involved in care.

Under Domain 4, midwives are required to demonstrate knowledge and understanding of pre-existing, current and emerging complications and additional care needs that affect the woman, including their potential impact on the woman’s health and wellbeing; and the ability to recognise and provide any care, support or referral that may be required because of any such complications or needs.

They should also demonstrate knowledge, understanding, and the ability to recognise complications and additional care needs regarding embryology and foetal development, adaptation to life and the newborn infant.

They must be able to use evidence-based, best practice approaches to respond promptly to signs of compromise and deterioration in the woman, foetus, and newborn infant, and to make clinical decisions based on need and best practice evidence, and act on those decisions.

Under Domain 6, midwives are required to demonstrate the ability to use evidence- based communication skills when communicating and sharing information with the woman, newborn infants and families that takes account of the woman’s needs, views, preferences, and decisions, and the needs of the newborn infant by actively listening, recognising and responding to verbal and non-verbal cues, and responding to women’s questions and concerns with kindness and compassion.

They are particularly required under Domain 6 to:

• keep, and securely store, effective records for all aspects of the continuum of care for the woman, newborn infant, partner and family by presenting and sharing verbal, digital and written reports with individuals and/or groups, respecting confidentiality; by clearly documenting the woman’s understanding, input, and decisions about her care and informing and updating interdisciplinary and multiagency colleagues about changes in care needs and care planning, and update records accordingly.

• respond to any questions and concerns and recognise the woman’s own expertise of her own pre-existing conditions, demonstrate the ability to measure and record vital signs for the woman and newborn infant, using technological aids where appropriate, and implement appropriate responses and decisions, demonstrate the ability to work in partnership with the woman to assess and provide care and support across the continuum that ensures the safe administration of medicines.

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• recognise, assess, plan, and respond to pre-existing and emerging complications and additional care needs for women and newborn infants, collaborating with, consulting and referring to the interdisciplinary and multiagency team as appropriate and a prompt call for assistance and escalation as necessary.

• monitor deterioration using evidence-based early warning tools, respond to signs of infection, sepsis, blood loss including haemorrhage, and meconium- stained liquor, keep accurate and clear records, including emergency scribe sheets,

• work in partnership with the woman and in collaboration with the interdisciplinary and/or multiagency team to plan and implement midwifery care for women and newborn infants as appropriate to implement necessary interventions when physical complications occur.

We only approve courses of midwifery education once we are satisfied that the course provider has met the standards of education and training that we have set as being necessary for midwives to achieve our standards of proficiency. This is the framework prescribed by our legislation which gives us assurance that newly qualified midwives entering the NMC register will be able to deliver safe, effective, respectful, kind, compassionate, person-centred midwifery care.

We do not refer to hyponatraemia specifically in our standards. Our standards are high level and outcome focused. This is because we believe the detail is better situated within curricula to reflect that evidence changes and practice experiences and assessment can be developed accordingly. We will develop and publish a scenario to inform student midwives and midwives about this condition for the start of the next academic year and raise awareness with our education colleagues.

Continued Practice and Revalidation

To maintain registration with the NMC, every nurse, midwife and nursing associate on our register must 'revalidate' every three years. This is to ensure they remain capable of safe and effective practice. The revalidation process requires nursing and midwifery professionals to demonstrate that they have practised for at least 450 hours, obtained at least 35 hours of continuing professional development, including 20 hours of participatory learning, reflected on their practice and obtained five pieces of practice related feedback.

Revalidation encourages nurses, midwives and nursing associates to promote lifelong learning. It requires professionals to reflect on their practice and how the Code applies to their day-to-day work. This is how we ensure that those on our register continue to maintain the knowledge and skills required for safe and effective

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care in the UK. Links to our revalidation guidance can be found here: What is revalidation? - The Nursing and Midwifery Council (nmc.org.uk).

The NMC Code and Fitness to Practise

Paragraph 10 of The Code sets out our expectations in relation to record keeping including that registrants must keep clear and accurate records relevant to their practice. Specifically, registrants must:

1. complete records at the time or as soon as possible after an event, recording if the notes are written some time after the event;
2. identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need;
3. complete records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements;
4. attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation;
5. take all steps to make sure that records are kept securely;
6. collect, treat and store all data and research findings appropriately. We will investigate alleged breaches of the Code when we become aware of them. In appropriate circumstances we enforce the standards set out in the Code through fitness to practise proceedings. Fitness to practise proceedings can result in a range of outcomes, ranging from the provision of advice to the registrant by the NMC to removal of the registrant from the register.

We are taking steps to investigate the concerns raised in relation to this incident to establish whether we need to take any regulatory action to protect the public and maintain our regulatory standards. Further information about our fitness to practise processes can be found here: How we regulate and the types of concerns we look into - The Nursing and Midwifery Council (nmc.org.uk).

We recognise the impact that FtP proceedings can have on families, which is why we have a Public Support Service (PSS) to help support people through the process and understand how the investigation process works. Through it, our public support officers can answer individual questions or provide one-to-one meetings and help explain the different decisions that could be made. We have been engaging with Orlando’s family through the investigation process. More information about our PSS can be found here NMC public support service - The Nursing and Midwifery Council

The PFD report mentions that there was also a doctor on duty who failed to recognise the potential risk of hyponatraemia. Whilst our statutory remit does not extend to doctors, we have shared this information with the GMC in accordance with our fitness

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to practise information handling guidance (ftp-information-handling-guidance.pdf (nmc.org.uk)) in case they need to carry out further investigations.

Conclusion

We take the concerns you raise in the PFD report and the circumstances leading to Orlando’s death very seriously. We are committed to taking steps that are within our powers to address the concerns raised. We will do this by taking specific action to address any fitness to practise concerns we identify in relation to professionals on our register, sharing necessary information with the General Medical Council so they can take any action required to protect the public, and developing a scenario to inform student midwives and midwives about hyponatraemia to raise awareness of the condition.

I hope this provides reassurance that we are taking appropriate action to address the concerns you have raised. Once again, I offer my heartfelt condolences to Orlando’s family. If you have any further questions concerning this case or the steps we are taking, please do not hesitate to contact us.