Midwives cannot bear all the blame

Poor administration, note-taking, drug management and patient care are all laid at the door of the midwives, with a compliant HSSD executive left looking out of touch.

The new board has apologised for that and promised to rectify the mistakes with deeds as well as words.

It is clear, however, from both the outgoing minister and the new chief executive, that HSSD feels badly let down by its NHS local supervisory authority, which was tasked with auditing the midwifery service.

A draft annual report by the LSA was never completed but found to be lacking in scrutiny and rigour. An under-qualified lay auditor who helped compile it was appointed at the last minute and the report was allowed to fester as events surrounding the baby's death overtook it.

The department was then exposed to the full extraordinary NMC review. That review is a thorough dissection of a slipshod organisation but lacks detail in several crucial areas.

Firstly, the four supervisors of midwives who bear the brunt of the criticism had been sent on enforced leave of absence, so investigators were unable to ask them any questions.

None of those midwives has had an opportunity to publicly defend their actions and there are four careers in the balance. While the department may be keen to move on, it has a duty of care to ensure that all its staff gets a fair hearing.

Secondly, the NMC has examined solely the operation of midwife services. The role of doctors in Loveridge Ward has therefore been largely pushed to one side pending the General Medical Council's broader review into maternity services.

Finally, while the report may have been sparked by the death of a newborn, it gives no indication of what went wrong, who might be responsible and how it might be rectified.

The department must not allow understandable caution about a sensitive subject to cause the finger of blame to settle by default solely on the most obvious target, midwives.