Today’s East Kent report isn’t the only independent investigation into NHS maternity services published in recent years, but that makes its findings even more crucial.
The themes identified by the Independent Investigation into East Kent Maternity Services, led by Baby Lifeline Honorary President Dr Bill Kirkup, are sadly too familiar.
As are the circumstances through which the investigation came about: through their trauma and grief, families somehow finding the energy to fight for answers.
We owe a huge debt of thanks to those whose dedication to finding out exactly what happened to their babies, and refusal to accept false information and hallow assurances, has led to us all knowing the truth. They’ve provided us with another opportunity to prevent avoidable tragedies in the future.
Whether we choose to learn from today’s report – and the Morecambe Bay and Shrewsbury and Telford reports that preceded it – is now down to us.
Key points: ‘Reading the signals: Maternity and neonatal services in East Kent – the Report of the Independent Investigation’
- The investigation examined East Kent Hospitals University NHS Foundation Trust’s maternity services in two hospitals, The Queen Mother Hospital in Margate. and the William Harvey Hospital in Ashford, between 2009 and 2020
- The report details that, over that period, the Trust provided clinical care that was “suboptimal” and led to significant harm
- The report shows that, during this period, there were multiple missed opportunities that should have led to problems being acknowledged and tackled effectively
- Had care been given to the nationally recognised standards, the outcome could have been different in nearly half of the 202 cases assessed by the Investigation’s panel. The outcome could have been different in 45 of the 65 baby deaths – more than two-thirds of cases.
- The report acknowledges that it includes “minimum estimates” of the frequency of harm, with the panel having only worked with families who volunteered to be involved in the report
- Alarmingly, the panel has “not been able to detect any discernible improvement in outcomes or suboptimal care” in the decade between 2009 and 2020
Alongside listening to families, the Investigation involved interviews with 112 current and former staff at East Kent Hospitals University NHS Foundation Trust, and with others whose work brought them into contact with the Trust’s maternity and neonatal services.
The themes identified are:
- Failures in teamwork: The report refers to “grossly flawed teamworking among and between midwifery and medical staff”.
- Failures in professionalism: “Staff were disrespectful to women and disparaging about the capabilities of colleagues in front of women and families,” says the report.
- Failures of compassion: “Caring for patients in any setting requires not only technical skills but also kindness and compassion. This is no less true for mothers and babies in maternity care,” states the report. “Yet we heard many graphic accounts, from staff as well as families, that showed just how far from the required standards behaviour had fallen at the Trust.”
- Failure to listen: Which, “directly affects patient safety, as we found repeatedly in the Trust’s maternity services, because vital information is ignored,” says the report.
- Failures around investigations: “…there appears to have been a collective unwillingness to engage with families and a reluctance to invite them to contribute to investigations; some families were not even made aware that an investigation was taking place,” explains the report.
- Failures when responding to investigations: For example, one midwife recalled how, when new guidelines were introduced in response to incidents but no one explaining why: “Staff [weren’t] involved in improvement plans and yet they [knew] what went wrong. They [knew] how it could be fixed but they weren’t invited to comment.”
Today’s report makes for shocking reading, including harrowing case studies and quotes that build a full picture of an organisation “characterised by internal and external denial with many missed opportunities to investigate and correct devastating failings”.
Individual families’ stories are unique, but the problems that led to their trauma are, unfortunately, not. The issues identified at East Kent are recognisable.
We’ve seen them in Baby Lifeline Honorary President Donna Ockenden’s review of maternity services at Shrewsbury and Telford NHS Trust, which was published in March this year, and within ‘The Morecambe Bay Investigation’ into maternity and neonatal services in University Hospitals Morecambe Bay NHS Foundation Trust, also led by Dr Bill Kirkup, published in 2015.
Meanwhile, many of the same themes are likely to be investigated by Donna Ockenden in her Independent Review into Maternity Services at the Nottingham University Hospitals NHS Trust, which launched last month.
Not enough has been done to learn from the lessons in previous investigations, as Dr Bill Kirkup himself told BBC Radio 4’s Today programme this morning:
“When I reported on Morecambe Bay maternity services in 2015, I did not imagine for one moment that I would be back in seven years’ time talking about a rather similar set of circumstances and that there would have been another two large, high-profile maternity failures as well on top of that.”
“[…]This cannot go on. We have to address this in a different way. We can’t simply respond to each one as if it’s a one-off, as if this is the last time this will happen. We have to do things differently.”
At Baby Lifeline, we support the recommendations in the East Kent report, which are (in summary):
Recommendation 1
- The prompt establishment of a Task Force with appropriate membership to drive the introduction of valid maternity and neonatal outcome measures capable of differentiating signals among noise to display significant trends and outliers, for mandatory national use
Recommendation 2
- Those responsible for undergraduate, postgraduate and continuing clinical education be commissioned to report on how compassionate care can best be embedded into practice and sustained through lifelong learning
- Relevant bodies, including Royal Colleges, professional regulators and employers, be commissioned to report on how the oversight and direction of clinicians can be improved, with nationally agreed standards of professional behaviour and appropriate sanctions for non-compliance
Recommendation 3
- Relevant bodies, including the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives and the Royal College of Paediatrics and Child Health, be charged with reporting on how teamworking in maternity and neonatal care can be improved, with particular reference to establishing common purpose, objectives and training from the outset
- Relevant bodies, including Health Education England, Royal Colleges and employers, be commissioned to report on the employment and training of junior doctors to improve support, teamworking and development
Recommendation 4
- The Government reconsider bringing forward a bill placing a duty on public bodies not to deny, deflect and conceal information from families and other bodies
- Trusts be required to review their approach to reputation management and to ensuring there is proper representation of maternity care on their boards
- NHS England (NHSE) reconsider its approach to poorly performing trusts, with particular reference to leadership
Recommendation 5
- East Kent Hospitals University NHS Foundation Trust to accept the reality of these findings; acknowledge in full the unnecessary harm that has been caused; and embark on a restorative process addressing the problems identified, in partnership with families, publicly and with external input
Today needs to be a turning point for NHS maternity services across the country, and so we must work together with an agreed understanding of the problems and build a united vision of the steps that need to be taken to ensure safer maternity services for all.
Baby Lifeline will do all it can to help facilitate this through research, training, and continuing to learn together for a safer maternity future.