The Ombudsman investigated three cases in which local statutory supervision of midwives failed, all of which occurred at Morecambe Bay NHS Foundation Trust. The cases clearly illuminate a potential muddling of the supervisory and regulatory role of supervisors of midwives. The current arrangements do not always allow information about poor care to be escalated effectively into hospital clinical governance or the regulatory system. This means the current system operates in a way that risks failure to learn from mistakes, which cannot be in the interests of the safety of mothers and babies and must change. Working with the Nursing and Midwifery Council (NMC), the Professional Standards Authority for Health and Social Care, NHS England and the Department of Health, the Ombusdman has identified two key principles that will form the basis of proposals to change the system of midwifery regulation: that midwifery supervision and regulation should be separated; that the NMC should be in direct control of regulatory activity. The Department of Health should convey these recommendations to its counterparts in Northern Ireland, Scotland and Wales and develop proposals to put these principles into effect.

The Ombudsman investigated three cases in which local statutory supervision of midwives failed, all of which occurred at Morecambe Bay NHS Foundation Trust. The cases clearly illuminate a potential muddling of the supervisory and regulatory role of supervisors of midwives. The current arrangements do not always allow information about poor care to be escalated effectively into hospital clinical governance or the regulatory system. This means the current system operates in a way that risks failure to learn from mistakes, which cannot be in the interests of the safety of mothers and babies and must change. Working with the Nursing and Midwifery Council (NMC), the Professional Standards Authority for Health and Social Care, NHS England and the Department of Health, the Ombusdman has identified two key principles that will form the basis of proposals to change the system of midwifery regulation: that midwifery supervision and regulation should be separated; that the NMC should be in direct control of regulatory activity. The Department of Health should convey these recommendations to its counterparts in Northern Ireland, Scotland and Wales and develop proposals to put these principles into effect.

This report investigates Mr L's complaint that North West Strategic Health Authority (SHA) failed to carry out adequately its functions as the Local Supervising Authority for midwives in relation to open and effective care provided for his son, Baby L which contributed to Baby L's death. This followed earlier infant and maternal deaths at Furness General Hospital, the hospital where Mrs L gave birth to Baby L. It also investigates Mr L's complaint that the SHA failed to deal with his complaint about this effectively. The Ombudsman upheld the initial complaint and agreed, in respect of the other two complaints, the functions of the SHA were not carried out properly but that no injustice arose to Mr L as a result.

Mrs M went into Furness General Hospital in July 2008 for the birth of her son. Sadly, there were problems during her birth and she died after the birth despite attempts to resuscitate her. He son, Baby M, died the next day because he had been deprived of oxygen during the birth. Two of the Local Supervising Authority's Supervisors of Midwives, Midwife A and Midwife B, reviewed the records and decided that there were no midwifery concerns that would warrant a supervisory investigation. Mr M said that, because of that decision, he and his wife's family had not been able to mourn the deaths of mother and baby. The Ombudsman found that: Midwife A should have identified a number of failings in the care provided to Mrs M who was a high-risk mother because of diabetes and having induced labour. Baby M's heart should have been monitored at regular intervals using continuous fetal heart monitoring from the moment Mrs M arrived in the delivery suite. The Strategic Health Authority should have gone much further than they did in investigating the original decision not to undertake a supervisory investigation. As a result they did not give Mr M an evidence-based explanation of that decision.

This report from the Parliamentary and Health Service Ombudsman investigated "Midwifery supervision and regulation" in respect of a complaint against the North West Strategic Health Authority which failed to carry out adequately its functions as the Local Supervising Authority for midwives in relation to open and effective supervisory investigations of midwives following their baby son's stillbirth at Furness General Hospital (part of University Hospitals of Morecambe Bay NHS Trust) on 6 September 2008. The Ombudsman upheld the complaint.

Global ethics addresses some of the most pressing ethical concerns today, including rogue states, torture, scarce resources, poverty, migration, consumption, global trade, medical tourism, and humanitarian intervention. It is both topical and important. How we resolve (or fail to resolve) the dilemmas of global ethics shapes how we understand ourselves, our relationships with each other and the social and political frameworks of governance now and into the future. This is seen most clearly in the case of climate change, where our actions now determine the environment our grandchildren will inherit, but it is also the case in other areas as our decisions about what it is permissible for humans beings to do to each other determines the type of beings we are. This book, suitable for course use, introduces students to the theory and practice of global ethics, ranging over issues in global governance and citizenship, poverty and development, war and terrorism, bioethics, environmental and climate ethics and gender justice.