Recommendation 32: Reform Local Supervising Authority for midwives
From Report of the Morecambe Bay Investigation, published 3 March 2015.
Recommendation
The Local Supervising Authority system for midwives was ineffectual at detecting manifest problems at the University Hospitals of Morecambe Bay NHS Foundation Trust, not only in individual failures of care but also with the systems to investigate them. As with complaints, our remit was not to examine the operation of the system nationally; however, the nature of the failures and the recent King's Fund review (Midwifery regulation in the United Kingdom) lead us to suppose that this is not unique to this Trust, although there were specific problems there that exacerbated the more systematic concern. We believe that an urgent response is required to the King's Fund findings, with effective reform of the system. Action: the Department of Health, NHS England, the Nursing and Midwifery Council.
In brief (written by this site)
In commentary published in February 2026, the Department of Health and Social Care and NHS England stated that the recommendation was implemented and closed, explaining that the Nursing and Midwifery (Amendment) Order 2017 separated supervision from regulation and that a new non-statutory supervision model, A-EQUIP, had been rolled out across the UK (DHSC and NHS England, Feb 2026). Previously, the Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).
AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026. The record below is the sources' own words.
Government response
83. We accept this recommendation. We will therefore modernise the regulatory regime for midwifery. 84. The statutory supervision of midwives was designed in 1902 to protect the public. It no longer meets the needs of current midwifery practice. Reports and recommendations by the Parliamentary and Health Service Ombudsman and Kings Fund found that midwifery regulation was structurally flawed as a framework for public protection, and highlighted that statutory supervisory structures encourage confidentiality in a way that does not always contribute to improving practice or systems and can be perceived as protecting the midwife rather than women or babies. This is borne out by the findings of the Morecambe Bay Investigation where the process of statutory supervision was ineffective at identifying the root causes for the many distressing incidents; at identifying and addressing poor practice amongst midwifery staff; and most importantly in addressing the families concerns. 85. In addition, the Government committed in March to the removal of the Nursing and Midwifery Council's oversight of midwifery supervision, and will work with the UK chief nursing officers to design a new system of supervision that is proportionate and recognises the importance of managing risks and promoting safety, as well as the professional development of midwives. Our intention is to act as swiftly as possible to legislate, and we intend to do this by introducing an Order in Council made under s60 of the 1999 Health Act. 86. Midwifery supervision is important for providing clinical supervision and professional development for midwives resulting in high standards of safe care for mothers and babies. Removing midwifery supervision from statute provides an opportunity to design a new system that enables a clear separation between the regulation of midwives (the role of the Nursing and Midwifery Council) and the supervision of midwives. England, Scotland, Wales and Northern Ireland are already working together to design this new system, which will include how the system will operate in future and where responsibility for its oversight will go. However, statutory supervision must continue until the law changes and a new system is in place and so as the Nursing and Midwifery Council and Government nurse leaders in the four countries have made clear, Trusts must not disestablish supervisor posts or other structures until that time.
How this response relates to the recommendation
Site note: This is the Department of Health's response, "Learning not blaming" (Cm 9113, July 2015), to the Morecambe Bay Investigation and two other reports. The department has been the Department of Health and Social Care since January 2018, and the rows are filed under that name. Every word is the department's, including where it reports what another body has done or will do.
Delivery
DHSC and NHS England say completed (27 February 2026)
The Thirlwall Inquiry has noted action taken in response to this recommendation.
The Nursing and Midwifery (Amendment) Order 2017 separated the function of midwifery supervision, which is the responsibility of the employer, from regulatory activity, which is the responsibility of the NMC. This brought the regulation of midwives into line with the arrangements for other regulated professions and means that supervisors are no longer involved in regulatory investigations and sanctions.
Subsequently, A-EQUIP a new, non-statutory model of supervision for midwives was developed and rolled out in each of the four countries of the UK with NHS England leading this work in England. The new model focuses on the professional and developmental aspects of the role.
Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Implemented – Closed”. Table row: section 23.2 No. 32, PDF page 650-651.
DHSC states no delivery position (15 May 2024)
The Nursing and Midwifery (Amendment) Order 2017 separated the function of midwifery supervision, which is the responsibility of the employer, from regulatory activity, which is the responsibility of the Nursing and Midwifery Council. This brought the regulation of midwives into line with the arrangements for other regulated professions and means that supervisors are no longer involved in regulatory investigations and sanctions.
Subsequently, A-EQUIP, a new, non-statutory model of supervision for midwives was developed and rolled out in each of the four countries of the UK with NHS England leading this work in England. The new model focuses on the professional and developmental aspects of the role.
From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024), The Department of Health and Social Care
Site note: DHSC's own comments on progress, supplied to the Thirlwall Inquiry in February 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). They are not a finding of the Inquiry. Table row: section 20.2 No. 32, PDF page 613-615.
Department of Health and Social Care says in progress (24 February 2020)
Both the Parliamentary and Health Service Ombudsman’s and Dr Bill Kirkup’s reports following Morecambe Bay were critical of the Local Supervising Authority system provided for in legislation for midwives.
The Nursing and Midwifery (Amendment) Order 2017 separated the function of midwifery supervision, which is the responsibility of the employer, from regulatory activity, which is the responsibility of the Nursing and Midwifery Council. This brought the regulation of midwives into line with the arrangements for other regulated professions and means that supervisors are no longer involved in regulatory investigations and sanctions.
Subsequently, a new non-statutory model of supervision for midwives has been developed and rolled out in each of the four countries of the United Kingdom with NHS England leading this work in England. The new model focuses on the professional and developmental aspects of the role.
Earlier statement on delivery (1)
Department of Health and Social Care (8 March 2017)
The proposals in this Order will result in a clear separation of supervision and
regulation of midwives. The NMC, as the regulator, will be in direct control of all
regulatory activity under its existing framework. The Secretary of State for Health
accepted the recommendations of the Kirkup Review and the PHSO Report in relation
to midwifery supervision and committed to amending the NMC’s legislation.
From: Explanatory Memorandum to the Nursing and Midwifery (Amendment) Order 2017 (SI 2017/321)
Site note: The Department of Health's Explanatory Memorandum to the Nursing and Midwifery (Amendment) Order 2017 (SI 2017/321), which removed the statutory supervision of midwives. The memorandum carries no date; the row is dated 8 March 2017, the day the Order was made. The Department of Health has been the Department of Health and Social Care since January 2018.
What other bodies have found
In their own words. These do not change the delivery statement above.
Thirlwall Inquiry legal team (15 May 2024)
Department of Health response (July 2015):
We will therefore modernise the regulatory regime for midwifery.
“Government committed in March to the removal of the Nursing and Midwifery Council’s oversight of midwifery supervision, and will work with the UK chief nursing officers to design a new system of supervision that is proportionate and recognises the importance of managing risks and promoting safety” (p. 86)
Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review colours its Extent of Implementation cell for this recommendation green, which it uses to mark evidence, identified by the legal team, that a recommendation has been clearly implemented. Table row: section 20.2 No. 32, PDF page 613-615.
Source
Responsible bodies
Themes and tags
Who has spoken
- Department of Health and Social Care
Response, delivery statement - DHSC and NHS England
Delivery statement - DHSC
Delivery statement - Thirlwall Inquiry legal team
Finding