Skip to main content
Search
Quick exit
The Report
Volume II
Part One (continued)
Chapter 18

Chapter 18. Nursing and Midwifery Council

Previous
Chapter 17
July 2016: Redeployment of and support for Letby
Next
Chapter 19
Speak Out Safely

Contents

Introduction

  1. The Nursing and Midwifery Council (NMC) has four broad areas of responsibility in respect of the 854,000 nurses, midwives and nurse associates on its register:*
    1. education, training and standards
    2. registration
    3. revalidation
    4. fitness to practise.

Its activities are funded by the annual subscriptions of its members, currently £120 per annum.†

  1. By the time of the Inquiry hearings, there had been a change of senior staff at the NMC. Evidence was given by the Acting Chief Executive and Registrar, Ms Helen Herniman. Ms Herniman is an accountant and until 2021 her career had been in finance. She was for some years the Chief Finance Officer for the Law Society. In 2021, she joined the NMC as the Interim Executive Director of Resources and Technology Services. From 4 July 2024, she served as the Acting Chief Executive and Registrar. She was due to return to her former role in January 2025 on the appointment of an Interim Chief Executive. I am grateful to Ms Herniman for shouldering much of the burden of the NMC’s response to the Inquiry. She relied, understandably, on the written statement of Ms Andrea Sutcliffe CBE, former Chief Executive and Registrar of the NMC, who resigned due to ill health on 4 July 2024.

Employer Link Service

  1. The NMC’s Employer Link Service was developed in response to Sir Robert Francis KC’s report of his Inquiry into Mid Staffordshire NHS Foundation Trust. Its purpose is to advise and support employers with concerns about nurses, midwives and nursing associates on the NMC register. In her written statement, Ms Sutcliffe wrote and Ms Herniman confirmed that the Employer Link Service aims to encourage robust local investigation where there is concern relating to nurses or midwives. Where that was successful, the number of fitness to practise referrals would reduce, with a clear benefit to the NMC.
  2. The Employer Link Service was piloted between September 2015 and operated substantively from April 2016. There were six Regulation Advisers, who reported to an Assistant Director who reported to the Director of Fitness to Practise. The Employer Link Service has access to lawyers and other professionals within the wider NMC.
  3. On 22 July 2015, the NMC published a manual for the Regulation Advisers (Employer Link Service Regulation Adviser Manual). The Manual describes the Regulation Adviser as:
    “the first point of contact for the DoNs/CNs or HoMs [Directors of Nursing / Chief Nurses or Heads of Midwifery] when they wish to discuss urgent issues, escalate concerns, or seek advice and guidance. If an RA [Regulation Adviser] is unable to assist the DoNs/CNs or HoMs they should discuss the matter with colleagues internally before providing the DoNs/CNs or HoMs with a response, or sign post the DoNs/CNs or HoMs to an appropriate member of staff who can deal with their query.”1
  4. In 2016, Regulation Advisers were, and still are, expected to hold regular meetings with the Directors of Nursing on ongoing cases and raise awareness about the range of enquiries they can help with. The Regulation Advisers were also available “as needed” to provide expert advice on how to deal with patient safety risks, fitness to practise thresholds for referral and queries about revalidation.2
  5. Where an employer makes a referral of a nurse to the NMC (on advice from the Employer Link Service or otherwise), the NMC considers whether to restrict the practice of the individual subject to the referral. An interim order may be imposed, removing the individual from practice or placing restrictions on their practice while an investigation takes place.3 Those powers are in place only once a referral has been made.

Involvement with the Countess in 2016

  1. When Ms Kelly made contact with the service in July 2016, the Employer Link Service had only been operating for three months. Ms Herniman described it as an “inexperienced function” at the time.4
  2. Mr Tony Newman, a Regulation Adviser, gave evidence to the Inquiry. He joined the NMC in April 2015 as a senior project manager after 33 years working for the Post Office in a security role. He was appointed to the role of Regulation Adviser in May 2016.
  3. Mr Newman explained that, at that time, when he received a call from an employer he had three broad options:
    1. Advise the employer to make a referral to the NMC.
    2. Advise the employer not to make a referral to the NMC.
    3. Advise the employer to investigate and/or manage the concern locally.5
  4. This was a gloss on the provisions of the Manual, which set out the three outcomes thus:
    1. refer the nurse [or] midwife to the NMC for investigation. The RA [Regulation Adviser] should encourage the provision of appropriate evidence, remind the DoN/CN or HoM [Directors of Nursing / Chief Nurses or Heads of Midwifery] of the importance of continuing local action and manage expectations around outcomes
    2. deal with the issue locally, with monitoring and review, for future update with the RA
    3. deal with the issue locally”6

As Mr Newman acknowledged, the advice given to employers about the need to refer can be important in protecting patients.

Mr Newman’s initial contact with Ms Kelly, July 2016

  1. Ms Kelly sought a meeting with Mr Newman in early July 2016. This was shortly after the deaths of Baby O and Baby P and at a time of intense activity in the Countess when the consultants were pressing for Letby to be removed from nursing duties and for the police to investigate. The hospital was also about to downgrade the neonatal unit. A telephone meeting was arranged, which took place on 6 July 2016, between Mr Newman, Ms Kelly and Ms Hodkinson. In accordance with the NMC guidance, Mr Newman summarised the conversation in an email he sent to Ms Kelly, copying in Ms Hodkinson. At 14:04 the same day, Ms Kelly made some corrections that Mr Newman accepted.
  2. The email, as corrected by Ms Kelly, recorded that there was an increase in mortality of babies on the neonatal unit, and continued:
    • Each death has been the subject of a clinical team case review.
    • The reviews have produced no evidence as to a lack of competence by individuals or the team.
    • …
    • … one registrant … has been present at nearly all these incidents.
    • Highlighted text starts. struck-through text starts The trust End of struck-through text Some clinicians . End of highlighted text. are concerned that the registrant may present a serious risk to public safety although no evidence is available at this time.
    • The Highlighted deleted text: trust board . End highlighted deleted text. executive team are due to meet today (6/7/16) to decide if this registrant will be reported to the Police to investigate.”7
  3. Mr Newman agreed in evidence that the totality of the information amounted to a potential concern about a connection between deaths and an individual. He pointed out: “[T]here was never an allegation that she could be causing deliberate harm or that there was serious negligence.”8 He agreed that there was an inference to be drawn that some clinicians were concerned that the registrant had killed babies. He said: “Yes, which is why I took the time to actually record the conversation … it crossed my mind.” Mr Newman told the Inquiry that it was the only time in eight and a half years in the role that he has ever recorded a conversation in a follow-up email in this way.9
  4. Mr Newman considered, correctly in my view, that his inexperience affected how he handled the call: “At the time, I think this was probably only the second call that I ever took on the advice line … this could even have been the first … So it was my uncertainty as to the level of risk at the time which probably caused me to follow up in writing.”10 His instinct to do so was undoubtedly right and it happened to be consistent with the Manual, which required Regional Advisers in all such cases to send an email to Directors of Nursing enclosing a record of the telephone meeting and inviting confirmation of content and errors to be corrected; this is what Mr Newman did on this occasion.11
  5. Mr Newman said that during the call he advised Ms Kelly to manage and investigate the case locally. This was in keeping with the NMC approach, as expressed by Ms Herniman. He explained that he did not advise Ms Kelly to refer the case to the NMC because
    “[w]e wouldn’t be able to take any action. We wouldn’t be able to consider it for an interim order without further information or evidence of deliberate harm. So we were in a really difficult situation.”12 Mr Newman said that, if he had advised Ms Kelly to refer the case, it would have sat in the screening section until evidence was presented.13 He explained that he advised local management and investigation of the case because “there was no allegation and there was no evidence to support [it]”.14
  6. Mr Newman did not sufficiently probe the information he was being given. The Manual provided a useful Regulation Adviser Case Referral Checklist, prompting the Regulation Adviser to ask relevant questions, such as “What is the risk to patients/public in allowing the nurse or midwife to continue to practise unfettered?” and “Does the local investigation and management satisfy you that the issue is being appropriately managed?”15
  7. Ms Herniman reflected: “Had we have asked further questions, shown more curiosity, … we may have received information which would have potentially led us to give different advice regarding the referral.”16 In evidence, she agreed that it would be helpful for the Employer Link Service to have a checklist with concise pertinent questions.17 I hope this is now in place. If it is not, urgent steps should be taken to provide it to the Regulation Advisers. She agreed that the handling of the call underlines the importance of the recommendation in the Allitt Inquiry that awareness of deliberate harm should be heightened in the minds of staff. Ms Herniman said, “I can understand why it would be beneficial to always have that in — at the forefront when we are receiving any information into us as the regulator”18 because it may lead to a conversation developing about deliberate harm. That reminder should be embedded in the training and checklists provided to all Regulation Advisers.
  8. At the very least, Mr Newman should have referred the matter to his line manager, the Assistant Director, before providing a response, or he should have referred Ms Kelly to someone with experience in screening. Had he referred the matter to his line manager, it is likely that he would have been asked to call Ms Kelly and obtain more information immediately to allow the NMC to assess the risk. Instead, Mr Newman decided, based on little information, that the matter need not be referred and that local investigation should continue. The Manual says that a matter may be left for local investigation “if local processes are robust and there is no presenting patient risk”.19 Mr Newman was not in a position to assess the first point and the Manual makes clear that it is not the Regulation Adviser’s role to do so. Quality assurance of the local governance or investigation process is left firmly with the organisation conducting the process.20 As to the second, I infer that he did not think there was a potential risk to other patients. That may be because the significance of the information that there was no issue about the nurse’s competence escaped him (just as it seems to have escaped so many others). In any event, if he had asked those questions, I am not confident that he would have been provided with all of the relevant information and concerns.

Peer review and benchmarking

  1. Mr Newman explained that after the call he spoke to an experienced lawyer in the Fitness to Practise Directorate and informed them of the information he had received. He said that the lawyer agreed that, without evidence or further information to suggest the registrant posed a risk, the correct advice was to manage locally or investigate further. He added that his advice went through a peer review (in which other Regulation Advisers consider the call and the advice given) about a week after the call, on 19 August 2016, and that the team agreed with his advice.21
  2. The notes from that meeting (at which Mr Newman was present) record that, “following a conversation with KG [Mr Kristian Garsed, Regulation Adviser], this should be discussed further at the benchmarking meeting. This is potentially really serious. TN [Mr Newman] to follow-up by emailing the DoN [Director of Nursing].”22 At the end of the record, there is a note to the effect that, “[c]onsidering the above circumstances [as set out in Mr Newman’s email summarising his discussion with Ms Kelly], the NMC would need to be advised of both the trust board decision to report to the Police and any subsequent action taken by the Police … I would also recommend another [advice] call to take place following confirmation of any Police action.”23 It is not clear who made these remarks. The peer review meeting concluded that this call and the advice given should be referred to the following benchmarking meeting and that Mr Newman should follow up by emailing Ms Kelly.
  3. Mr Newman emailed Ms Kelly on 23 August 2016, asking for an update. Ms Kelly did not reply until 31 August 2016. In the meantime, on 24 August 2016, Mr Newman’s advice was discussed at the benchmarking meeting with senior lawyers, at which he was present. Mr Newman said that this meeting also agreed with the advice he had given.24 The comments of the reviewers (not exhaustive) refer to “looking into the actions of the midwife, cannot find action or conduct that the midwife is accountable. This is a matter for police investigation.” That is followed by “we do not have a plausible allegation”. The comments continue that, “unless there is medical negligence – this is a matter for the police … the clinical governance risk manager should be assessing the risks in relation to this … did not find clinical failing therefore need to look into the chain of causation”. And “feels like the Trust has this matter in their hands”. Finally, it is agreed that Mr Newman will “follow-up”.25
  4. Mr Newman said: “Looking back at it now, it seemed like [the call from Ms Kelly on 6 July 2016] was an initial enquiry to maybe test the waters with the regulator.”26 By the time he gave his evidence to the Inquiry, Mr Newman knew what Ms Kelly had said in her evidence, and he said he now understood that certain information had been withheld from him during the call. He said that, if Ms Kelly had said directly that the hospital suspected the individual was harming babies, then “that would have set off all sorts of alarm bells and we probably would have said, even with a lack of evidence because we would recommend that they contact the police, we would recommend a referral at that time so that we could contact the police”.27 In truth, Ms Kelly would never have said ‘the hospital suspects’ – hence her correction of Mr Newman’s first email, changing the words “the trust” to “some clinicians”. This relatively subtle correction underlined the fact that the executive did not suspect anything. At most, if asked, she would have said ‘the consultants suspect’.
  5. Mr Newman (and, more importantly, all those who were said to have approved his advice) knew that “some clinicians are concerned that the registrant may present a serious risk to public safety”.28 This was said in the context of deaths on a neonatal unit and, it was said, in the absence of concerns about competence. I do not follow why, in those circumstances, the fact that clinicians thought the nurse presented a serious risk to public safety was not sufficient to set off alarm bells with Mr Newman and all those who reviewed his advice. Where it was thought that a nurse may be harming babies, whether deliberately or not, there was cause for concern at the NMC.
  6. In the call of 6 July 2016, Ms Kelly had told Mr Newman that there was to be consideration of whether to call the police that afternoon. This may have given the impression that the hospital was dealing with the matter in a responsible way but the reference to calling the police should have rung alarm bells in an experienced (or at least adequately trained) Regulation Adviser and in those who were reviewing and/or benchmarking. Such a person should have asked why consideration was being given to calling the police and asked to be informed of the decision the following day in case it affected his view. In fact, calling the police was not discussed that day or the following day. Nothing more was said about it at that stage.
  7. I bear in mind that Ms Kelly consistently said to others that there was no evidence against Letby, so she would have said the same to Mr Newman. She did not tell him what was known about the unexpected and unexplained nature of the deaths nor did she mention the fact that, when Letby had been moved off the night shift, the unexpected deaths stopped happening at night. Nor did she mention that the most recent deaths had occurred during the day when Letby was on shift. Mr Newman’s lack of experience meant that he asked no probing questions about the nature of the doctors’ concerns, nor did he ask whether the nurse was currently working on the unit. Whilst the NMC does not have a corporate responsibility for safeguarding, its members have individual responsibility.29 Mr Newman did not ask about safeguarding steps, nor did his colleagues. This was an important omission. As Ms Herniman accepted, the NMC should have been prompting the hospital to consider its safeguarding responsibilities.

Follow-up

  1. On 23 August 2016, Mr Newman emailed Ms Kelly to seek an update. This was the day before the benchmarking meeting. Ms Kelly responded on 31 August 2016 and told Mr Newman that: (a) the Trust had undertaken a thorough internal review and nothing of significance was identified; (b) “on receiving views from our clinicians”, the step was taken to remove Letby from clinical duties; (c) there had been “no indication to discuss” the matter with the police; (d) an external review had been commissioned; and (e) Letby would remain redeployed until the outcome of the review.30 As with her initial call to Mr Newman, this was an economical approach to the facts.
  2. This was the first time Mr Newman had heard that the nurse was being moved from the unit to non-clinical duties in light of the clinicians’ views. It was a clear sign that there was a need to protect patients. He said that it looked as though the Trust was taking the right steps to protect against future risk. That was true, as far as it went. But it did not answer the question why this was necessary, nor did it protect patients in other settings (should there be any). Mr Newman accepted this and acknowledged that he did not ask the Trust to alert the NMC were Letby to move to work elsewhere. It did not occur to him. Ms Herniman accepted that the NMC should have asked Ms Kelly questions about why the nurse had been moved from clinical duties. The answer would probably have been that it was for her protection or because the consultants had insisted on it. Either response should have prompted more questions and the answers should have prompted advice to the Trust to consider their safeguarding responsibilities.
  3. Mr Newman subsequently met Ms Hodkinson and Ms Kelly on 29 November 2016. He was told, for the first time (over four months after the event), that the neonatal unit had been downgraded because of the increase in mortality and that the independent review (the RCPCH report; see Chapter 20) had provided initial feedback that there was no risk to patient safety.31 The note of the meeting records that the plan was to have a phased approach to Letby’s return to the neonatal unit and that there were no grounds for referral of Letby to the NMC. The note of the meeting also records that the reviewers recommended a further, more detailed review of the cases by an external independent consultant.32 Mr Newman said he was aware that the clinicians still had concerns at the time. Significantly, he said he was not given any further detail about the nature of the allegations against Letby or why the clinicians were concerned.33 He conceded: “I didn’t at the time ask specifically what their concern was.”34 He was asked whether he should have done and replied: “Yes, and I would now given the same call.”35
  4. Mr Newman conceded that, at the time, he had no idea of the quality of the investigation at the Countess. He was candid that the emphasis was put on the Trust’s investigation. “So I understand what you are saying, how can we leave the burden or responsibility down to NHS Trusts? But that’s simply the way it was then and it still is, to a certain extent.”36 This echoed what was in the Manual and what Ms Sutcliffe and Ms Herniman said about the aim of the service being to encourage robust local investigation. This keeps responsibility (and therefore all the resource implications) within the hospital, locally, rather than inviting a referral on fitness to practise, which would require the NMC to investigate. I do not doubt that local investigation is a good first principle but the NMC was faced with matters of real gravity. A local investigation of unknown quality and scope could never be the right response to those concerns.

NMC actions after the arrest of Letby, May 2017 to December 2023

  1. On 17 May 2017, Ms Kelly requested a call with the NMC in relation to the RCPCH report. She sent a press release announcing a police investigation into the neonatal deaths. Mr Kristian Garsed, Regulation Adviser in the Employer Link Service, spoke to her on 18 May 2017. Mr Garsed records Ms Kelly saying:
    “[T]here was a view held by several medical colleagues that a registrant (Lucy Letby) may be the common denominator … based on an identification of her as having been present on most, but not all of the occasions, when infants collapsed and or died. However, as is noted in the RCPCH review there was no certain picture of who was present on these occasions, and the most in depth analysis undertaken of the staffing situation, did not extend to non-clinical staff. In addition, the registrant has apparently a very good professional history and a high degree of clinical credibility and was not present on all of the relevant occasions. Other staff were present on a similar number of relevant occasions.”37

I have set out on a number of occasions what was known by this stage. I will not repeat it here. It is sufficient to say that much of this account was misleading.

  1. Mr Garsed’s note of the call included his advice that: “[A]t this stage … there is nothing which could amount to an identifiable or sustainable allegation of impaired fitness to practise, however the outcome of the police investigation has the potential to be very significant, and if this individual or any other registrant is identified as having been involved … then plainly referral/referrals would be necessary.”38 Ms Herniman accepted on behalf of the NMC that it should have insisted that the police kept it up to date with their investigation.39 I agree.
  2. On 3 July 2018, the NMC learned through its media monitoring service that an individual had been arrested in connection with deaths at the Trust.40 Ms Kelly was contacted by the Employer Link Service and, on 5 July 2018, submitted the referral about Letby.41 In the referral, Ms Kelly set out a chronology, noting that on 27 June 2016 concerns had been raised verbally by paediatricians regarding increased neonatal mortality and that Letby was named as “allegedly being on duty a number of times when incidents had taken place”, but adding that there was “no evidence to suggest that this was a contributing factor to increased mortality”.42 The NMC Chief Executive, as part of an email discussion on 6 July 2018, said: “Of course we can’t and shouldn’t comment on the police investigation but we are able to say that for us to consider whether we should stop someone from working requires more than the fact of an arrest.”43 The media manager replied: “Yes there is no reason to be defensive, just explain why we are not in a position to restrict her practice.”44 It does not seem to have been appreciated that Letby had not been working as a nurse for nearly two years by this stage. An application for an interim order should have been made.
  3. For months, the legal department of the NMC debated whether or not to apply for an interim order. Views were divided. The view that prevailed was that an arrest was not sufficient evidence to justify an application for an interim order suspending a nurse’s registration. The fact that there was other evidence was either not appreciated or ignored. This underlined and reinforced the absence of probing in the early conduct of this case – but the early conduct was by an inexperienced Regulation Adviser. The lawyers should have done better.
  4. In evidence, Ms Herniman said:
    “[T]he NMC has reflected and has already changed the interim order guidance because it was felt on reflection of the Lucy Letby matter, as well as another case the GMC were involved in, as well as comparing our guidance to that of other regulators, we felt that the way the guidance was written didn’t give flexibility to, in extraordinary circumstances, [so] that you don’t have to have an individual being charged in order to make the application.”45
  5. The updated interim order guidance published in March 2024 refers to a document titled ‘Decision making factors for interim orders’. This currently states:
    “A criminal charge may well provide cogent evidence of a concern, particularly if we are satisfied that the decision to charge and prosecute the person was made following a robust consideration of the evidence. However, we do not always need to wait until a person has been charged before applying for an interim order, and in appropriate cases we may decide that a case should be put before a panel for interim order consideration prior to charge.”46
  6. The NMC’s position is that, had this guidance been in place at the time, a decision to suspend Letby on an interim basis may have been made sooner (for instance, at the point of arrest rather than charge).47 I am surprised by the reference to the NMC being “satisfied that the decision to charge and prosecute the person was made following a robust consideration of the evidence”.48 It is not at all clear in what circumstances the NMC would consider it appropriate to assess such a decision nor how they would do it. The NMC also refers to a new practice of holding case conferences in complex or sensitive cases, which includes expertise from a range of areas (legal, clinical and safeguarding), and notes that a relevant regulatory decision-making process document is being actively developed.49 Such a ‘decision-making process document’ must include a direction to establish what, precisely, is being referred and why. It should never again be possible for the NMC to be fobbed off, as it was here.
  7. Letby was charged on 11 November 2020. On 12 November 2020, the NMC decided to apply for an interim order. On 20 November 2020, she was made the subject of an interim order of suspension on the grounds of public protection and public interest. This was reviewed and maintained.
  8. It is the NMC’s view that – in light of changes they are making – were a similar call made to the Employer Link Service today, questions would be asked that would elicit information that would lead to the advice to refer the matter to the Fitness to Practise Directorate. The assertion that a similar call would lead to advice to refer, which was included in the written opening statement on behalf of the NMC, caused some consternation within the current team of Regulation Advisers. They wrote to the Inquiry to say that they thought the outcome would be the same now as it had been in 2016.50 There were discussions within the NMC, at the end of which I was informed – and I accept that the Regulation Advisers were satisfied – that the difference between then and now is the fact that further questions would be asked that would elicit information that would lead to the appropriate advice being given.51
  9. On 19 January 2021, questions were asked within the NMC about the corporate memory of previous cases. The cases of Beverly Allitt, Colin Norris, Benjamin Green and Victorino Chua were listed. Ms Herniman said in evidence that she had heard of the Allitt case but was unaware of the others.52 Ms Herniman acknowledged the need for a heightened awareness of the possibility of deliberate harm even in a hospital, as directed by Sir Cyril Clothier in the Allitt Inquiry.53
  10. Letby was convicted on 18 August 2023, and on 22 August 2023 the NMC notified her that her case would be considered by the Case Examiners. She was referred to the Fitness to Practise Committee on 21 September 2023 for hearing, and on 12 December 2023 she was struck off the nursing register. She indicated in writing that she did not object to the application but restated her innocence.
  11. In evidence and in their opening statement, the NMC rightly acknowledged a number of mistakes and failures.54 However, these were most unfortunately undermined by the written closing submissions (unsigned and undated but not prepared by Counsel for the NMC), which reverted to the language of things that “could have been” done differently.55 It should be understood by now that things should have been done differently. The language used, repeatedly, neither recognises failings and mistakes nor, importantly, takes responsibility for them. A particularly egregious example of language avoiding responsibility is at paragraph 35 of the written closing submissions. It reads: “As explained in paragraph 4 above, the NMC has reflected on the events at CoCH [the Countess] and its own processes and has identified opportunities to learn and improve.”56 This euphemism is unhelpful. The idea that errors should first be characterised as opportunities for learning may be appropriate in some situations. It is plainly not appropriate here. Before lessons can be learned there must be an honest recognition and acceptance of errors. What needs to be said (and what the witnesses did say in evidence) is that mistakes were made. Things should have been done differently. The NMC failed in a number of respects. It is essential to recognise the failures and then to take steps to ensure that the same mistakes do not recur. I acknowledge that some steps have been taken to improve the Employer Link Service and the NMC processes more generally. I understand that a document has been disseminated designed to bring about cultural change.57

Revalidation

  1. Nurses have to renew their registration every three years. The process is described as revalidation.
  2. The online Cambridge English Dictionary defines ‘revalidation’ as “the process or act of making something or someone officially acceptable or approved again”. The dictionary gives examples of the word being used in a sentence, including: “Doctors will be required to demonstrate their fitness to continue practising, a process known as revalidation.”58
  3. The process for revalidating doctors meets that definition. On their website, the GMC say: “Every licensed doctor must revalidate to show they’re up to date and fit to practise, in line with the legislation that supports revalidation.”59 The revalidation process for doctors is considered the ‘gold standard’ process. It is detailed, onerous and expensive.
  4. Many other professions – nursing, pharmacy, the Bar – are required to renew their registration or practice certificate at given intervals. The renewal does not require revalidation. It generally requires self-certification that the applicant has completed a certain amount of work, professional development and, usually, a declaration of good character.
  5. On their website, in a section directed at applicants, the NMC define revalidation as “the process that all nurses and midwives in the UK and nursing associates in England need to follow to maintain their registration with the NMC”.60 It continues: “Revalidation is about promoting good practice, as well as strengthening public confidence in the nursing and midwifery professions. It’s important to know that it’s not about making an assessment of your fitness to practise [emphasis added].”61 On behalf of the NMC, Ms Herniman and Ms Sutcliffe both reinforced that the process does not include an assessment of fitness to practise. That occurs only when a registrant is the subject of a specific referral.
  6. To achieve revalidation, a nurse is required to have completed 450 hours of clinical practice over the previous three years and 35 hours of continuing professional development, as well as written accounts of practice and reflection. There is a requirement for the nurse to declare they are of good health and good character and that they have insurance.62 Registrants are also required to declare if they have received a police charge, caution or conviction, and they must also declare whether they have been subject to a determination by a professional or regulatory body. There is no requirement to alert the NMC to any outstanding complaints or claims or even to a restriction on practice at the time of the application or in the three years under consideration. Nor is the application affected by a period away from practice.
  7. Confirmation of the form is required.63 The nurse seeking revalidation chooses the confirmer. The NMC suggests that it should be a line manager.64 The current guidance to confirmers reads: “[I]t will be your role to check whether a nurse, midwife or nursing associate has met the requirements of revalidation.”65 That is not consistent with what follows, which informs the confirmer that most nurses keep a portfolio of evidence and use it to demonstrate how they have met the requirements. The following then appears: “As a confirmer, you are not being asked to make an assessment of a nurse[’s] … fitness to practise, or assess the quality of the individual’s work. You are simply looking to see that they can demonstrate they have met the requirements.”66
  8. The confirmer’s role therefore is purely administrative. As the NMC website confirms, there is no assessment of the nurse’s abilities, the quality of their work or their fitness to practise. The confirmer is not asked to confirm the truth of the contents of the form. Nor are they expected to correct errors. The sole question is – does the form demonstrate that the registrant has met the requirements for revalidation, as defined by the NMC. In my view, this is not revalidation as it is generally understood.

Letby’s revalidation

  1. Letby applied for revalidation on 30 August 2017.67 Ms Farmer was her confirmer.68 By this stage, Letby had not been working in a clinical capacity for over a year. Senior members of the Fitness to Practise Directorate of the NMC knew this. Notwithstanding this, Letby’s application for revalidation was accepted by the NMC on 14 September 201769 because, the NMC explained, on the date she submitted her revalidation application Letby was not the subject of an interim suspension order. Had she been the subject of such an order, she would not have been able to revalidate. The fact that she had not been in practice for a year was, it seems, not relevant. Letby also confirmed that she was not the subject of any police charges, cautions or convictions. Had she been, she may not have been revalidated. Ms Farmer had confirmed that the information on the form met the requirements of the process.
  2. Ms Herniman acknowledged, rightly, that improvements are needed to the revalidation process, which was introduced nearly ten years ago. A decision was made not to introduce a process in which the nurse is appraised and their practice examined as a doctor’s would be. It is not suggested that this compromises patient safety. In other professions, as with nurses, fitness to practise is scrutinised only when a complaint is made and a referral is made to the fitness to practise panel. There are significant numbers of such referrals and there is a backlog. A process that considers experience, professional development and insight, if properly used, should strike the right balance between protecting the public and regulating nurses. I have recently been informed that the NMC is currently reviewing revalidation and consulting on changes, and that this includes consideration of strengthening the role of confirmers. This is a welcome step.
  3. For this process to be more than a box-ticking exercise, both the nurse and the confirmer should be required to confirm the truth and accuracy of the contents of the form and any other written documentation forming part of the application. Consideration should also be given by the NMC to a requirement to declare any complaints or warnings, restrictions on practice or gaps in practice, so that they form part of the information to be considered when renewing registration. Often a gap in a nurse’s practice is for parental leave. Sometimes it is the result of a health issue or, much more rarely, of some reservation about the nurse’s practice. The nature and extent of the gap in practice, and its consequences, would be for the NMC to consider but in my judgement such gaps should be declared and considered. I bear in mind the evidence from Ms Sutcliffe: “When a concern is raised about a professional on our register’s conduct, health, or competence we investigate through our fitness to practise process.”70 In the examples I have given above, it is possible that a complaint or a health issue or a reservation about practice might be relevant to the nurse’s fitness to practise, in which case that process could then be initiated. This would be a question for the NMC to consider on a case-by-case basis. What is not acceptable is for people to slip through the regulatory net because there are two processes – the first of which does not require transparency, the second of which requires a referral.
  4. It is striking that Letby received revalidation when she had not worked on a ward for over a year, was not permitted to work on a ward and a police investigation was taking place. She had been on observational work experience placements at Alder Hey when she had no patient-facing role in the hospital that was employing her. No questions seem to have been asked. All the boxes were ticked.
  5. That there was no sharing of information between the fitness to practise team, Employer Link Service and the revalidation team at the NMC in this case is regrettable. The NMC draw attention to the fact that from 2022 the Employer Link Service, fitness to practise and registration teams have developed an intelligence sharing hub, as a forum for colleagues to share any potential regulatory risk, including emerging risks where it is felt a fitness to practise referral may be required. I also note the NMC announcement on their website in September 2025 about their increased use of technology.71 I would expect this sort of information to be easily shared electronically across teams.

Name change

  1. Revalidation gives false reassurance about the level of scrutiny that has taken place. Renewal of registration would be more accurate. The fact that Ms Sutcliffe and Ms Herniman (and, for that matter, the NMC website) spent so long explaining what revalidation is not, is a clear indicator that the use of the term revalidation is at best unhelpful and at worst misleading.

Footnotes

  1. * As at the end of March 2025.

  2. † Fee correct at the time of writing.

Endnotes

  1. 1 INQ0108447/35

  2. 2 INQ0108447/35

  3. 3 Nursing and Midwifery Order 2001, article 29 and 31 (https://www.legislation.gov.uk/uksi/2002/253/article/29; https://www.legislation.gov.uk/uksi/2002/253/article/31)

  4. 4 Helen Herniman 8 January 2025 90/14

  5. 5 Tony Newman 12 December 2024 207/14-23

  6. 6 INQ0108447/42

  7. 7 INQ0002951; the strikethroughs and yellow highlights in the email copy are Ms Kelly’s corrections.

  8. 8 Tony Newman 12 December 2024 213/16-18

  9. 9 Tony Newman 12 December 2024 214/4-21

  10. 10 Tony Newman 12 December 2024 214/23 to 215/7

  11. 11 INQ0108447/69

  12. 12 Tony Newman 12 December 2024 216/15-18

  13. 13 Tony Newman 12 December 2024 216/12-14

  14. 14 Tony Newman 12 December 2024 219/24-25

  15. 15 INQ0108447/64

  16. 16 Helen Herniman 8 January 2025 93/21-24

  17. 17 Helen Herniman 8 January 2025 128/22 to 129/9

  18. 18 Helen Herniman 8 January 2025 93/9-12

  19. 19 INQ0108447/38

  20. 20 INQ0108447/42

  21. 21 Tony Newman 12 December 2024 215/11 to 216/14

  22. 22 INQ0108434/38

  23. 23 INQ0108434/38

  24. 24 Tony Newman 12 December 2024 229/17-22

  25. 25 INQ0108439

  26. 26 Tony Newman 12 December 2024 218/2-4

  27. 27 Tony Newman 12 December 2024 218/17-22

  28. 28 Tony Newman 12 December 2024 212/22-24

  29. 29 INQ0002419/17

  30. 30 INQ0002964/1

  31. 31 INQ0002447/6

  32. 32 INQ0002447/6

  33. 33 Tony Newman 12 December 2024 234/17-21

  34. 34 Tony Newman 12 December 2024 235/25 to 236/1

  35. 35 Tony Newman 12 December 2024 236/6

  36. 36 Tony Newman 12 December 2024 223/4-21

  37. 37 INQ0002449/1

  38. 38 INQ0002449/2

  39. 39 Helen Herniman 8 January 2025 103/25 to 104/5

  40. 40 Witness statement of Helen Herniman INQ0107926/8/para 33(h)

  41. 41 Witness statement of Helen Herniman INQ0107926/8/paras 33(h) to 33(i)

  42. 42 INQ0002455/7

  43. 43 INQ0108595/6

  44. 44 INQ0108595/5-6

  45. 45 Helen Herniman 8 January 2025 112/5-13

  46. 46 NMC, ‘Decision making factors for interim orders’, last updated 25 March 2026
    (https://www.nmc.org.uk/ftp-library/interim-orders/applying-the-interim-order-test)

  47. 47 Written Closing Submissions on Behalf of the Nursing and Midwifery Council 4 March 2025 14/para 41a

  48. 48 NMC, ‘Decision making factors for interim orders’, last updated 25 March 2026
    (https://www.nmc.org.uk/ftp-library/interim-orders/applying-the-interim-order-test)

  49. 49 NMC 12 September 2024 5/paras 14b-14c

  50. 50 INQ0108377/1

  51. 51 Witness Statement of Helen Herniman INQ0108437/2 para 5

  52. 52 Helen Herniman 8 January 2025 80/1-17

  53. 53 Helen Herniman 8 January 2025 92/21 to 93/5

  54. 54 NMC 12 September 2024 78/17 to 102/3

  55. 55 Written Closing Submissions on Behalf of the Nursing and Midwifery Council 4 March 2025

  56. 56 Written Closing Submissions on Behalf of the Nursing and Midwifery Council 4 March 2025 9/para 35

  57. 57 NMC, Culture Transformation Plan 2025-2028, 19 March 2025 (https://www.nmc.org.uk/globalassets/sitedocuments/independent-reviews/2025/nmc-culture-transformation-plan-2025.pdf)

  58. 58 Online Cambridge English Dictionary (https://dictionary.cambridge.org/dictionary/english/revalidation)

  59. 59 GMC, ‘Revalidation for doctors: questions and answers’, 2026 (https://www.gmc-uk.org/registration-and-licensing/managing-your-registration/revalidation/revalidation-for-doctors-questions-and-answers#Do_I_need_to_revalidate)

  60. 60 NMC, ‘What is revalidation?’, last updated 26 May 2021 (https://www.nmc.org.uk/revalidation/overview/what-is-revalidation)

  61. 61 NMC, ‘What is revalidation?’, last updated 26 May 2021 (https://www.nmc.org.uk/revalidation/overview/what-is-revalidation)

  62. 62 Witness statement of Andrea Sutcliffe INQ0002412/17/paras 75-76

  63. 63 Witness statement of Andrea Sutcliffe INQ0002412/17/para 76

  64. 64 NMC, ‘Confirmation’, last updated 26 May 2021 (https://www.nmc.org.uk/revalidation/requirements/confirmation)

  65. 65 NMC, ‘Information for confirmers’, last updated 26 May 2021 (https://www.nmc.org.uk/revalidation/confirmers-and-employers/confirmers)

  66. 66 NMC, ‘Information for confirmers’, last updated 26 May 2021 (https://www.nmc.org.uk/revalidation/confirmers-and-employers/confirmers)

  67. 67 Witness statement of Helen Herniman INQ0107926/4/para 22

  68. 68 Witness statement of Andrea Sutcliffe INQ0002412/59/para 241

  69. 69 Witness statement of Andrea Sutcliffe INQ0002412/59/para 242

  70. 70 Witness statement of Andrea Sutcliffe INQ0002412/19/para 87

  71. 71 NMC, ‘NMC launches new strategy for 2025-2027’, 25 September 2025 (https://www.nmc.org.uk/news/news-and-updates/nmc-launches-new-strategy-for-2025-2027)

Previous
Chapter 17
July 2016: Redeployment of and support for Letby
Next
Chapter 19
Speak Out Safely