1. The Trust should consider implementing a more organised approach to the initial job and role planning process for new consultants. This should include clear identification of the consultant’s line management arrangements, and the responsibility for their clinical supervision.
2. The workplace induction process for new consultants should be reviewed to ensure that appropriate mentoring and/or buddying arrangements are in place to enable consultants joining the Trust to have a resource to assist them to integrate quickly to their role and their division.
3. Line managers should intervene with clinicians more promptly to address and resolve relationship problems where they might adversely affect patient safety (especially in small specialties). Line managers should consider whether informal approaches to resolve any problems, such as encouraging colleagues to talk through issues are needed. Support may also be considered for more explicit conflict resolution or mediation if problems persist.
4. The Chief Medical Officer’s team should develop written guidance on the commissioning of external reviews to ensure they are properly specified, that their findings and recommendations are actioned, and that appropriate monitoring arrangements are established to track progress with any improvement plans. This guidance should be developed in collaboration with line management. The agreed guidance should be set out in a standard operating procedure (SOP).
5. To ensure that reliable records are available in any further investigation or review, we recommend that the Trust should maintain more comprehensive written records or file notes of meetings and important conversations with people involved in patient safety issues and their investigation.
6. In evaluating reports produced by external reviewers we recommend that the commissioner, or the manager responsible for interpreting the report, should always speak with the reviewer to test understanding of the findings and any recommendations flowing from the report.
7. Outcomes, findings and recommendations from an external review should be shared with a senior clinician in the specialty for the purpose of understanding the findings, conclusions, and recommendations.
8. The Chief Medical Officer (CMO) should develop a protocol for ensuring that the handover from their office of an external report for action is managed in concert with the specialty or divisional manager.
9. We recommend that a named individual should be held responsible for ensuring that actions are taken consequent upon a review. That individual should be responsible for ensuring any improvement plan for a clinician whose practice has been reviewed is properly resourced and enabled by the Trust.
10. The Chief Medical Officer’s office and the named individual should agree what monitoring and reporting mechanisms are needed to track progress, and to ensure key steps and outcomes are accurately recorded.
11. We recommend the CMO’s office, and the named individual should sign off and record the closure of any actions arising from the review.
12. The CMO’s team should ensure that the findings and conclusions of any external review are shared with the management team involved and that an appropriate plan is developed and implemented that sets out the actions to be taken and by whom.
13. The CMO’s team should satisfy itself in the commissioning and delivery of an external review that any information and/ or findings are recorded in the appropriate Trust data streams and risk registers. Any completed review should be assessed by the CMO’s team to identify any need to exercise the Trust’s duty of candour.
14. We recommend that the Chief Medical Officer and the Chief People Officer should produce guidance that clearly sets out the respective roles of appraisers and line managers in the management of consultants. This guidance should also clarify who is responsible for clinical supervision of consultants and how that supervision should operate.
15. To improve the confidence that the Trust has in the competence of its surgeons we recommend that the Chief Medical Officer should consider developing appropriate mechanisms to ensure surgical practice is routinely observed by qualified colleagues.
16. The Trust should consider whether to develop a more formal mechanism to share outputs from appraisals with line management. Any concerns about a clinician’s practice, or factors that might affect it, need to be routed, with the clinician’s agreement, into the management of the Trust so that they can be considered and acted upon.
17. While the personal and medical content of Occupational Health referrals and reports are private to the individual, the Trust should assure itself that appropriate arrangements are in place for line management to understand whether any reasonable adjustments need to be made to support the individual to maintain good health and performance.
18. Line managers should be encouraged to be proactive in identifying and correcting excessive workload for their team members. Managers should be alert to the possible effect that staff carrying excessive workloads may have on patient safety and quality of care.
19. We recommend that the Trust should develop a more consistent approach to the establishment and management of MDTs. The aim should be to standardise, where appropriate, those common elements that apply to MDTs across the Trust. Such an approach could be set out in a Standard Operating Procedure (SOP).
20. The Trust should consider an audit of all existing MDTs to consider their effectiveness in enabling the consistent delivery of safe care. Such an audit should consider; clarity of the MDT’s aims; team working; use of data and information for decision-making, and regularity/inclusiveness of meetings.
21. The CMO and the Chief People Officer should establish an implementation working group to ensure that changes to clinical governance structures, processes and practice are embedded effectively across the Trust. The group should include corporate management, and staff from a ‘deep slice’ of the organisation to ensure representation from all the key groups responsible for patient safety.
22. The Trust should establish a structured process for supporting clinicians whose participation in MDT meetings is affected by health or interpersonal difficulties. The aim 291 should be to ensure that safe, collaborative clinical practice is maintained. This process should comprise early discussion of reasons for withdrawal; assessment of any risk to clinician or patients; mitigation of such risk; alternative mechanisms for peer review and monitoring of safe practice.
23. The CMO’s team should ensure that the Trust has the necessary procedures in place to meet the expectations of the IHPN Medical Practitioners Assurance Framework. 

The review concludes with a number of areas where the RDUH could consider improving its systems and process. In most areas there are improvements already underway and the findings in this review could add to them. The review recognises the importance of ensuring the culture of the RDUH in creating conditions where people can speak up and be heard, and for everyone, particularly (but not solely) women, to feel sexually safe at work. The review also offered some opportunity to continue the work that is being done to improve the support for managing doctors well in the RDUH. In particular, the storage and sharing of information, escalation processes and the importance of diverse expertise when managing complex situations are areas for focus. Finally, there is opportunity to improve the process of communication within the RDUH in situations involving confidentiality, safety and where staff are impacted by external events.

• a history of negligent and fraudulent clinical practice that had led to patient harm
• examined patients in way that did not respect their dignity
• bullied and intimidated staff members, including making unsolicited sexual contact.

Doctor F was also having an affair with a senior manager at the Trust, and the group believed this led to Doctor F being protected during investigations.

During the investigation, it came to light that Doctor F was the subject of an ongoing investigation into the death of a patient, Patient A, who died during surgery while under the care of Doctor F. Following this information becoming available, the investigation focused significant effort on examining what led to the death of Patient A, and what action the Trust took or did not take following their death.

The report also details harms to other patients of Doctor F, including:

• a paused operation which didn't proceed to the next phase for 90 minutes with no communication with senior colleagues.
• poor preoperative documentation and consent processes
• a spinal procedure involving multiple misplaced screws and a life-threatening haemorrhage due to direct vessel damage.

The report's author says that the patients and/or their families should receive a full and transparent explanation and an apology for the level of care they received from Doctor F and the Trust.

• The review team identified that the colorectal cancer outcomes appeared to be acceptable, including within the normal range for 30 day mortality. However, they considered that the National Bowel Cancer Audit data showed that there was a disproportionately high rate of urgent or emergency surgery admissions for colorectal cancer patients (54%), which was far higher than the national average (20%) and the regional average.
• The review team considered that the National Emergency Laparotomy Audit data showed a higher than national average 30 day mortality for emergency laparotomy patients, with poor performance for timeliness of arrival in theatre and involvement of geriatricians in the care of high-risk patients. They were of the view that this reflected sub-optimal care for emergency patients, which was a threat to patient safety.
• Major concerns were identified by the review team over high rates of cancellations of elective patients.
• The review team noted that there was a high volume of complaints from patients. The most common theme of complaints was around communication, in terms of patients having a clear understanding of and expectations of their treatment.
• The review team found there was dysfunctional team working and a lack of cohesion and unity amongst the surgical teams and within the general surgery department. They were told that consultant surgeons were dismissive and disrespectful towards other members of staff and displayed hierarchical behaviours towards allied healthcare professionals, particularly junior members of staff.
• Reports of negative culture and behaviours within the general surgery department and wider Trust was of concern to the review team. They heard reports of staff witnessing or hearing about instances of bullying and harassment.
• Serious concerns about a wide disconnect between staff within the surgical teams and the executive leadership within the Trust were identified. The review team found that there was a lack of visible presence of the executive leadership ‘on the ground’ amongst staff, for example on the wards, and a reluctance to engage with the department, and therefore a lack of true understanding of the challenges affecting clinicians.
• The review team were particularly concerned to learn that a ‘culture of fear’ existed amongst staff when it came to the executive leadership team. There were concerning reports of bullying by members of the executive leadership team, with instances of confrontational meetings with individual consultant surgeons, when they were told to “sit down, shut up and listen”, with no ability to express their own concerns, and where they were alone and outnumbered.
• The review team found that staff were reluctant to respond to whistle-blowing requests, given they had experienced instances of other staff members raising concerns through such mechanisms reportedly facing bullying and being dismissed. Whilst the appointment of the Chief of Surgery was found to be positive, as staff felt when they raised concerns they would be taken more seriously, the review team found that the listening stopped at this level, with repeated reports that communication with the executive leadership team was poor.

The report makes a number of recommendations for the Trust to address the patient safety risks that it identifies, including measures to ensure better control over the emergency and elective workload, improve communication, improve the effectiveness of multidisciplinary team working and to break down the disconnect between clinicians and the executive leadership team.

Related Reading

• “Had my concerns been taken seriously by medical staff, Lewis might still be alive today.” Simon Chilcott tells his son Lewis’s story (11 October 2023)
• Mistakes and 'mafia-like' culture at NHS Trust (BBC Newsnight, 29 November 2023)

The review team found a challenging staff experience that has manifested itself over a long period of time, has largely continued unchecked, and has created a culture where for many, an adverse working environment has become normalised. There is currently not a single defining culture at the Trust, but there are commonalities of experience. The culture is comprised of many individual views and interpretations which means staff experience the Trust in different ways. For many of the staff who engaged with the review, their experience of working in the Trust is compromised, with a range of concerns. These include not feeling valued and respected, often not feeling safe at work, and not connected to the wider organisation in which they serve. Staff also reported not feeling included and not having a voice that is heard and acted upon. For some staff this has impacted on their wellbeing.

Going forward, the Board must acknowledge the culture at UHB needs to significantly improve. The Board, supported by senior management and staff, must create the conditions for change. This should include zero tolerance for poor behaviour so staff feel they can contribute, collaborate, have their voice heard, and feel their work is valued. Staff should be empowered to lift their heads up and enabled to do the right thing. Empowerment should not be simply handing off responsibility to staff, but listening and engaging in co-production, development, and improvement.

The four fundamental shifts the review recommend are:

• A shift to openness and transparency.
• A shift to valuing people and ensuring equity and inclusion .
• A shift to ensuring culture directly connects to effective patient care.
• A shift to ensuring a physically and psychologically safe working environment.

The investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust revealed a series of serious patient safety failings between 2009 and 2020, which resulted in avoidable harm to patients and deaths. In its formal report, published on the 19 October 2022, it stated that if nationally recognised standards had been followed, the outcome could have been different in 97 of the 202 cases reviewed.

At the beginning of its response to the Investigation and its recommendations, the Government states that at a national level, the Minister for Mental Health and Women’s Health Strategy will chair a newly created maternity and neonatal care national oversight group. This will bring together the key people from the NHS and other organisations, including the CQC and HSIB, to look across maternity and neonatal improvement programmes and the implementation of recommendations from this and other maternity reviews, to ensure a joined-up and effective approach.

Summary of the Government response to each of the recommendations

Recommendation – 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.

 NHS England (NHSE) has established a Reading the Signals Data Co-ordination Group, referred to in this report as the co-ordination group, who will bring together a series of data projects which aim to make sure the right data will be used in the right way to identify and support trusts who may be vulnerable to bad outcomes.

NHSE have also formed a Maternity and Neonatal Outcomes Group, acting as a task force in response to the recommendation in the East Kent report. Chaired by Dr Edile Murdoch, this group has met and is progressing work towards the identification of outcome measures that will, as this recommendation states, differentiate signals among noise to display significant trends and outliers.

Recommendation – 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.

Department of Health and Social Care (DHSC) will lead the response to this recommendation in a central coordination role involving relevant national partners, closely supported by NHSE. It will coordinate activity to:

• Map how compassionate care is currently being taught at all levels and across professions, whether this be formally or as part of in practice training.
• Share good practice and examples of how barriers have been overcome with all those responsible for training, from higher education institutions to those providing preceptorship and clinical supervision at trust level, on the embedding of compassionate care.
• Identify where gaps depend on national level change or coordination and work with relevant bodies or other government departments to consider how these could be addressed. This will also consider how the government, NHSE and other arm’s length bodies can influence and support sustainable system level change.

Recommendation – 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.

DHSC will lead the response to this recommendation, in a central coordination role looking across the whole system. This work will be supported closely by NHSE. It will coordinate activity to:

• Map current responsibilities around oversight and direction.
• Share good practice and learning on proposed solutions to address gaps in roles and responsibilities in oversight and direction, and support for managing concerns about practice.
• Identify where gaps in oversight depend on national level change or coordination and work with relevant bodies or other government departments to consider addressing these. This will include examination of where regulators could contribute to identification of poorly performing trusts.

Recommendation – 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.

DHSC will lead the response to this recommendation in a central coordination role, with the close support of NHSE. It will coordinating reports that will:

• Provide evidence through experience and examine existing research on how and where teamwork is being done well.
• Bring together examples of good practice to support trusts and all those supporting teamwork to utilise as a resource of solutions to barriers and identified gaps.
• Consider whether, where gaps and barriers are identified, relevant bodies or government can support solutions.

Recommendation – 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.

DHSC will lead the response to this recommendation and be supported closely by NHSE. It will coordinate reports that will:

• Map how the support for junior doctors, and those who have yet to complete training including locums, is translated into practice, what access they have to development and how teamwork is embedded within this.
• Identify and share good practice and learning around proposed solutions to address gaps in roles and responsibilities for supervision for specific groups.
• Consider whether the government and its arm’s length bodies (ALBs) need to provide support to the system to address gaps and barriers.

Recommendation –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.

Recommendation – Trusts be required to review their approach to reputation management and to ensuring there is proper representation of maternity care on their boards.

Recommendation – NHSE reconsider its approach to poorly performing trusts, with particular reference to leadership.

The Government has provided one response to the above three recommendations which includes the following points:

•  The government acknowledges the failure to adhere to this duty of candour that was so evident in this report and recognises the need for action in this area in order to make sure the duty is effectively applied and to create a culture of candour throughout organisations.
• When considering the broader recommendation made by Dr Kirkup for a bill to place a “duty on public bodies not to deny, deflect and conceal information from families and other bodies”, the government will set out its position in response to Bishop James Jones’ 2017 report on the experiences of the families bereaved by the Hillsborough disaster in due course.
• To help monitor when reputation management is superseding transparency of trust boards, the CQC, as part of its new inspections approach, will continue to consider trust leadership at executive team and trust board level as part of its key lines of enquiry, using the well led framework.
• In the 2023 to 2024 financial year, NHSE is commissioning a support programme for board safety champions to focus on developing the leadership, culture and processes needed for them and their teams to be able to use qualitative and quantitative data to improve maternity and neonatal safety in their organisations.

Recommendation – The Trust 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.

In their response the Government note the actions that the Trust has taken following the publication of the report on the 19 October 2022, including that specific improvements in maternity and neonatology services will be overseen by a maternity and neonatal assurance group, reporting to the Trust’s board.

Related reading

• 'Reading the signals': Maternity and neonatal services in East Kent – the Report of the Independent Investigation (19 October 2022)
• Prevention of Future Deaths Report: Harry Richford (3 February 2020)
• Patient Safety Learning: Will lessons be learned? An analysis of the systemic failures in the East Kent Maternity report (17 November 2022)

The news article made reference to seven incidents and the names of five individuals were included. The report said that families were not always told the full facts of the circumstances surrounding the death of their relatives. In addition, the whistle-blower who reported these concerns to the Sunday Times also alleged that he had raised concerns about patient safety in NEAS a number of times and that he was bullied and victimised as a result of his actions. Some of the concerns raised by the whistle-blower were known in NEAS and the wider NHS system particularly in relation to some specific complaints from families and the robustness of coronial processes and reporting. The alleged incidents took place between December 2018 to December 2019

• clinical safety
• governance and leadership
• staff welfare
• culture.

Appendices 1-4 of the report map the specific recommendations with progress so far.

• Appendix 1 – Patient Safety Review (Mike Bewick and team – phase 1) recommendations implementation plan: April 2023
• Appendix 2 – Summary of the Culture Review by The Value Circle
• Appendix 3 – Well Led Diagnostic by NHS England
• Appendix 4 – UHB’s response to the Phase 1 recommendations

The review was commissioned following concerns raised in December 2022 relating to patient safety, leadership, culture and governance. As part of this response, NHS Birmingham and Solihull (ICB) announced three independent reviews focusing on:

• Patient safety and governance (Bewick Review) - commissioned by the ICB, overseen by experienced senior independent clinician, Professor Mike Bewick, former NHS England Deputy Medical Director.
• Well-Led review of leadership and governance – in conjunction with NHS England, using established methodology. 
• Culture - commissioned externally by UHB’s Interim Chair, incorporating findings from above.

In order to bring the conclusions and recommendations of these two pieces of work together and provide additional independent assurance, Professor Mike Bewick has been commissioned to support both remaining reviews and also return at a later date to update on progress on implementing the recommendations following this report. 

In the patient safety review, the independent review team set out two concerns and four groups of recommendations. As part of this, they also make clear that their ‘overall view is that the Trust is a safe place to receive care’. 

The review team have highlighted the need for better understanding of raised Hospital Standard Mortality Rates, concerns regarding levels of staffing, particularly nursing at Good Hope Hospital. The review also finds that ‘any continuance of a culture that is corrosively affecting morale and in particular threatens long term staff recruitment and retention will put at risk the care of patients’. This was supported by feedback from the Trust’s Medical Staff Committee.

The review team make 17 recommendations (available in the full report) across clinical safety, governance and leadership, staff welfare and culture, including:

• Haemato-oncology: 

1. A specific review of mortality should be conducted by an external specialist in this field with support from a governance lead. The terms of reference should include:
2. An independent retrospective review of all the deaths first analysed by Dr Nikolousis to establish any lessons learned
3. Consideration as to whether there an outstanding DoC responsibility relating to this patient cohort 
4.  All deaths in the year 2021/22
5. An assessment of how integrated the department is following the merger in 2018 with a focus on how leadership and accountability of the service currently functions.

• That prospective appointments of senior medical, nursing, and managerial leadership are reviewed with a focus on developing core skills, including those required for leadership, collaborative working methods, professional interaction, and disciplinary processes.
• In light of the tragic death by suicide of Dr Kumar - Together with HEE, a review of the processes to support doctors in training who are concerned about their mental health, ability to speak up freely about concerns with colleagues and a clear message that they will be listened to.
• That the concerns of senior clinicians, expressed by the Medical Staff Committee in January 2023, are addressed specifically as part of the Phase 2 cultural review.
• That the Trust commissions a partner to deliver awareness training on how to identify issues of bullying, coercion, intimidation and misogyny.

• Recommendation 1 (TEWV): It is clear from the research that patients and their families (and some staff) were ignored and that their concerns and complaints are now found to be, on the whole, justified. The Trust must seek assurance that complaints, concerns and feedback are taken seriously and managed in line with The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 particularly in relation to recording receipt of a formal complaint. Additionally, feedback and concerns on a service must be comprehensively reported and reviewed on a frequent basis, and importantly, that feedback is acted upon.
• Recommendation 2 (TEWV): Formal corporate decision-making processes and outcomes were difficult to trace and evidence. The Trust should seek assurance that there is a ratified minute of key organisational decisions.
• Recommendation 3 (TEWV): Action plans relating to West Lane Hospital were not connected to improvement programmes or risk registers. The Trust should ensure that there is strategic oversight of actions through the Board, Committee or working group where multiple interventions are involved. This will ensure that actions are not duplicated with other activities or overlooked. Using a programme approach around improvement plans and risk registers increases the accountability and enforceability around actions.
• Recommendation 4 (TEWV): There were issues with the consistent application of Duty of Candour at the Trust. The Trust should seek assurance that there are now mechanisms in place to assess that the Duty of Candour Policy is effectively implemented. Additionally, where there has been a death in a service, whether through self-harm/suicide or homicide, that families are given appropriate, meaningful, timely and compassionate family liaison and support through personal contact with a nominated officer of the Trust.
• Recommendation 5 (TEWV, CNTW, North East & North Cumbria ICB, Middlesborough Council, NHSE and provider collaborative, and CQC): TEWV, CNTW and System Partners need to seek assurance that they have resolved the problems associated with the clinical transitions phase (between services and child to adult). A compound recommendation is required to address this deficit:
  a) TEWV must provide assurance that a full gap analysis between the 2018 Healthcare Safety Investigation Branch (HSIB) investigation and its own position has been completed. As the Trust still delivers Tier 3 CAMHS services they should expedite a review of processes and procedures in relation to transitions.
  b) CNTW need to expedite a review of processes and procedures in relation to transition of CNTW young person inpatient to adult services.
  c) Patient as well as stakeholder feedback associated with transitions between CAMHS and other services (such as AMHT) should be sought and incorporated into service redesign by all parties.
  d) Effective governance surrounding transitions was not always in place. The good practice relating to transitions which is described within NICE Guidance should be translated into practice and delivered by all parties.
  e) Where a young person is in receipt of T4 care and transferring back to T3, there must be a joint response between health and the relevant local authority children’s services (in this case Middlesborough Council) so that the young person is prepared for life in the community and can be properly supported and their risks appropriately managed.
  f) ICBs, NHSE and provider collaboratives must ensure that providers with a PICU have a written protocol that details the pathway for discharge, including timescales for involving in arrangements, the families and the young person. This will ensure that, wherever possible, a young person is not suddenly transferred without adequate preparation.
• Recommendation 6 (TEWV): There was a gap between the development and successful implementation of important care initiatives (such as least restrictive practice), plans and evidence-based changes to practice. The Trust must seek assurance that there are implementation plans for new initiatives, policies or procedures and that these are evidence-based, being implemented correctly within services and monitored appropriately.
• Recommendation 7: There was a lack of systematisation in relation to the identification, mitigation and actioning of known risks at a ward, service and corporate level. A compound recommendation is required to address this deficit:
  a. TEWV must ensure that risk assessments for young people in CAMHS are based on a psychological formulation and are developed by a multidisciplinary team in conjunction with the young person and their family.
  b. TEWV must ensure that proper training is provided to staff around clinical risk management and how to ensure that action is taken consistently.
  c. TEWV must provide assurance that it meets the requirements of the new Patient Safety Incident Response Framework by 2023.
  d. The North East & North Cumbria Integrated Care Board (ICB), NHSE, and provider collaborative must seek assurance that TEWV has a robust environmental and ligature risk assessment process and the ability to respond effectively and urgently to mitigate risks identified through this process (including risks identified on Tunstall Ward).
  e. North East & North Cumbria Integrated Care Board must assure themselves that CNTW are following the NHS Child and Adolescent Mental Health Services Tier 4 (CAMHS T4): General Adolescent Services including specialist eating disorder service specification and the QNIC standards for use of mobile phones and social media access in inpatient environments.
  f. The application of robust risk assessment forms part of the CQC regulatory framework. The CQC should routinely examine the quality and consistent application of TEWV’s clinical risk assessment, clinical risk training and the relationships to local and corporate risk registers.
• Recommendation 8 (TEWV): The function of Executive team meetings in terms of operational involvement lacked clarity. The Executive team meetings must clearly define and record actions which they are directly responsible for, or, where actions have been delegated. The ET should recognise that it has the mandate to form task and finish groups.
• Recommendation 9: Safeguarding between mental health providers and system partnerships was insufficient to protect young people in West Lane Hospital. Despite the availability of Working Together Guidance, responsibilities and obligations internally and externally between agencies (providers and system colleagues) were confused, interpreted differently by individuals and consequently gaps developed. A compound recommendation is required to address this deficit:
  a. NHS England Specialised Commissioning, the North East & North Cumbria ICB and provider collaborative and the South Tees Safeguarding Children Partnership Board and LADO should now all reflect upon matters raised within this report and determine whether further internal review is required to ensure proper learning occurs within each respective agency. All relevant Safeguarding Children’s partnerships need to ensure that there are sufficient mechanisms in place to prevent a recurrence of the same.
  b. The North East & North Cumbria ICB and provider collaboratives should obtain assurance that provider organisations have sound systems and processes to safeguard young people in mental health facilities, and these provide regular robust assurance to NHS England Specialised Commissioning of effective working.
  c. Middlesbrough Council and Health providers/ key partners must ensure that there is clarity about the roles and responsibilities of each agency in the planning and delivery of care to young people in Tier 4 CAMHS provision to ensure that support is holistic and meets the educational; social; physical health and emotional needs of children and young people as well as their mental health needs.
  d. Local Authorities and Health providers must provide appropriate challenge where there are concerns about unsafe discharge arrangements from Tier 4 inpatient care, including appropriate escalation up to chief officers where concerns for children’s safety are high.
  e. Durham County Council must ensure that responses to referrals are completed within expected time frames, and subsequent assessments always incorporate the views of the family and young person.
  f. North East and North Cumbria Integrated Care Board and the Provider Collaborative must consider the impact and risks on Tier 4 CAMHS if a local Safeguarding Board is found to be weak or inadequate, or a local provider is found to have a major staffing issue.
  g. Where Safeguarding concerns are raised about a child, these must include a formal consideration of other vulnerable family members for the lifespan of care.
  h. Middlesbrough Council must respond formally to serious concerns raised about the care and treatment of a young person under their care and explore concerns with the family and the young person.
• Recommendation 10 (TEWV): Reporting structures were disconnected between various tiers of governance, and this prevented the ‘drill-down’ required for effective oversight and effective learning. The Trust must ensure rounded reporting arrangements to support proper Board assurance consisting of both hard evidence and soft intelligence. This should include a ‘trigger tool’ when a ward or department is experiencing ‘stress’, such as failing to complete training, debriefs, high sickness absence, low staff morale and this should be viewed alongside patterns of incidents, harms and complaints.
• Recommendation 11: There were gaps in relation to both the commissioning of effective services and in relation to the regulatory oversight in relation to West Lane Hospital. Assurance seeking activity was weak with a lack of sufficient scrutiny of both hard and soft intelligence. A compound recommendation is required to address this deficit:
  a. NHS England Specialised Commissioning and the Care Quality Commission (CQC) must ensure that when there is enhanced surveillance of services following quality concerns, the themes and patterns of all incidents are rigorously scrutinised and analysed.
  b. NHS England Specialised Commissioning, the provider collaborative and the North East & North Cumbria ICB, should work together with the Directors of Children's Services in the North East region. This is to ensure that services are commissioned which will meet the needs of the growing number of young people with complex needs and challenging behaviours that require integrated health and social care responses.
  c. A demand and capacity review (under the provider collaboratives programme and in association with each local authority) should be undertaken to ensure services have the appropriate capacity locally to minimise placing children out of area and to ensure the availability of suitable specialist care.
  d. TEWV/NHS England, the provider collaborative and Middlesbrough Council must provide assurance that all looked after children specifically with a diagnosis of autism have care provided that is in line with the NICE guidance on autism spectrum disorder in under 19s: support and management, recognising the challenges in the system.
• Recommendation 12: (NHS England) A full assurance review of progress against the recommendations contained within this report must be completed in 6-12  

TEWS response to the report

TEWV-assurance-statement-20-March-2023.pdf

"I wish to inform the House of the Government’s initial response to the report of the independent review into the maternity and neonatal services at East Kent University NHS Foundation Trust that was published on the 19 October 2022. NHS England commissioned Dr Bill Kirkup CBE to undertake this review following concerns about the quality and outcomes of care.

I would like to place on the record my gratitude to the families who came forward to contribute to this review, and to express my deepest sympathies for the loss and harm that Dr Kirkup discovered in the maternity and neonatal services at East Kent. I am also grateful for Dr Kirkup and his review team for his report. Taking each of the recommendations in turn:

1) The Government already has work underway to establish 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.

2i) Those responsible for undergraduate, postgraduate and continuing clinical education will be commissioned to report on how compassionate care can best be embedded into practice and sustained through lifelong learning.

2ii) Relevant bodies, including Royal Colleges, professional regulators and employers, will 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.

3i) Relevant bodies, including the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives and the Royal College of Paediatrics and Child Health, will 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.

3ii) Relevant bodies, including Health Education England, Royal Colleges and employers, will be commissioned to report on the employment and training of junior doctors to improve support, teamworking and development.

4i) The Government will consider in parallel with other relevant inquiries the duties placed on public bodies to share information with families.

4ii) Trusts will be required to review their approach to reputation management and to ensuring there is proper representation of maternity care on their boards.

4iii) The Government will continue to work with NHSE on its approach to poorly performing trusts and their leadership.

5) The Trust has already made a statement accepting the reality of these findings; acknowledging in full the unnecessary harm that has been caused; and embarking on a restorative process addressing the problems identified, in partnership with families, publicly and with external input."

We continue to work with NHS England and the Care Quality Commission regarding patient safety concerns at the Trust. Further information on how the recommendations are being implemented will be outlined in Spring 2023. The Department of Health and Social Care will also closely monitor progress on these recommendations alongside the recommendations of other maternity and neonatal service inquiries to improve standards of care for mothers and babies.

• Poor practice including a lack of proper clinical investigation.
• Inaccurate diagnosis.
• Poor prescribing practices.
• Poor record keeping.
• Lack of openness and effective communication.
• Inappropriate treatment
• The risks of clinicians working in isolation.

The expert panel has made specific recommendations for RQIA including:

• Ensuring that patients have direct access to doctors’ letters.
• Ensuring proper multidisciplinary team working.
• Tackling isolation in clinicians working alone.

These important recommendations are at the heart of addressing the failings of the care and treatment provided. Clinicians must be supported to adopt good practice, especially in using up to date best practice routes to diagnosis and treatments. They should be encouraged and facilitated to seek the support of peers and others to challenge and review their analysis and thinking. These are issues, not only for neurology services, but throughout the health and social care system.

Commissioned by the Department of Health and Social Care (DHSC) in February 2020, the Independent Investigation into East Kent Maternity services published its report last month highlighting patient safety failings in maternity and neonatal care services from 2009–2020 at two hospitals: Queen Elizabeth The Queen Mother Hospital at Margate and the William Harvey Hospital in Ashford.

This is another devastating report detailing cases of serious avoidable harm and preventable deaths in the NHS, stating that it found that:

“... those responsible for the services too often provided clinical care that was suboptimal and led to significant harm, failed to listen to the families involved, and acted in ways which made the experience of families unacceptably and distressingly poor.”[1]

It is a harrowing read, with its findings echoing many of the problems we have seen highlighted in other maternity care inquiries and reports in recent years, such as the Morecambe Bay Investigation and the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust.[2] [3]

The aspects of this report specific to maternity and neonatal care have recently been explored in more detail by charities such as Sands, Tommy’s, Baby Lifeline and Birthrights.[4] [5] [6] [7] In this article, we will analyse this report from a broader patient safety perspective, focusing on five key themes that are consistent with many other serious patient safety inquiries and reports in recent years:

• Failing to listen to patients.
• Still not learning from investigations.
• Poor behaviour and a corrosive blame culture.
• Lack of effective leadership for patient safety.
• Absence of an effective regulatory framework.

Having considered each of these issues in their wider context, we will then consider the recommendations made by this report, what we think needs to happen to prevent similar scandals in the future and the need for a fundamental transformation in our approach to patient safety.

Failing to listen to patients

A common theme that comes up repeatedly in inquiries and reports into serious patient safety failings is a failure to listen to patients when they raise concerns about care. At Patient Safety Learning we believe that patient engagement is key to improving patient safety and identify this as one of the six foundations of safer care in our report, A Blueprint for Action.[8] Patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account.

It is clear from the East Kent Maternity services investigation that too often this was not the case, with it stating that:

“An overriding theme to have come from the listening sessions is the tendency of midwives and doctors to disregard the views of women. In fact, in a significant number of cases, the Panel found compelling evidence that women and their partners were simply not listened to when they expressed concern about their treatment in the days and hours leading up to the birth of their babies, their concerns often dismissed or ignored altogether. In at least some of these cases, the Panel was able to draw a connection between that failure to listen and an adverse outcome.”[1]

The report highlights cases of patients being dismissed or ignored in a range of separate ways: being excluded and marginalised immediately after serious events, an unwillingness to engage with families in investigations, failures to explain risks and ensure patients were informed, and distressing incidents showing a basic lack of kindness and compassion. It also highlights that these issues only received full investigation thanks to the tenacious campaigning efforts of patients and family members themselves, noting that:

“In common with other investigations, the trigger for regulatory scrutiny and the commissioning of this Independent Investigation came from individual families who had been failed by the Trust. It was their persistence and determination to get to the truth that has led us to where we are now. It is disappointing that families continue to have to do this to substitute for ineffective safety monitoring by trusts and regulators.”[1]

There are no detailed recommendations in the report relating to improvements in this area, apart from a proposal for the DHSC to consider “bringing forward a bill placing a duty on public bodies not to deny, deflect and conceal information from families and other bodies”.[1] However, nationally this is acknowledged by the NHS as an area for improvement, with the importance of patient engagement and involvement set out in the NHS Patient Safety Strategy.[9] The NHS also published last year a new Framework for involving patients in patient safety to guide improvements in this area.[10]

Although this includes a number of commendable ideas, translating these principles into practice remains the key challenge. This requires resources, commitment and a willingness to proactively seek the insights of those with lived experience to be successful. Healthcare needs to restore the trust of patients and families so they can be assured that safety is a core purpose with their voices and experience being heard and ensuring that lessons are learned and applied to prevent future harm.

We are closely monitoring the implementation of the framework and await the subsequent evaluation of its impact on patients and families and safety improvement.

Still not learning from investigations

Patient safety incident investigations are an important source of patient safety learning, providing an opportunity to identify what went wrong and the actions needed to prevent a similar incident taking place in the future. However, too often in the NHS we still see examples of investigations not resulting in learning and improvement. This is a theme that also emerges from the East Kent Maternity services investigation, with it stating:

“Safety investigations were often conducted narrowly and defensively, if at all, and not in a way designed to achieve learning. The instinct was to minimise what had happened and to provide false reassurance, rather than to acknowledge errors openly and to learn from them.”[1]

The report noted that investigations could be inadequate, failing to identify where practice could be improved and that, as mentioned in the previous section, there was a reluctance to involve families in these processes. This problem is not specific to East Kent, with poor quality investigations also being a major theme in the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust published earlier this year. Describing the approach to root cause analysis (RCA) investigations at Shrewsbury and Telford, it said:

“It also identified that there was no culture of shared learning, that the RCAs often focused on the wrong issues, lacked system wide actions and focused instead on non-specific actions such as ‘share report widely’ and ‘learn from events’. There was no documentation that action plans were completed and recommendations often focused on individuals, rather than recommendations for system changes.”[3]

There are no detailed recommendations in the East Kent report about the need for improvements in safety investigations. However, this issue was picked up in the review of maternity services at Shrewsbury and Telford as an area for improvement, with it emphasising that “families must be involved in the investigative process and that lessons must be learned and implemented in a timely way to prevent further tragedies”.[3]

NHS England has also identified the need for improvement in patient safety investigations. This year they have published a new Patient Safety Incident Response Framework (PSIRF), setting out their approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety.[11] This new framework makes a welcome acknowledgement of the importance of engaging patients and families as part of the investigation process and ensuring that investigations result in a clear understanding of the causal factors of harm and actions needed to deliver safety improvements.

As with new initiatives around patient involvement, it is too early to say whether PSIRF will bring about significant changes to address the issue of poor-quality investigations highlighted in both the East Kent and Shrewsbury and Telford reports. It proposes a complex innovation in the NHS’s approach to incident investigation and review. We believe that its success will depend on having the right leadership and resources to support this transition, enabling organisations to move towards a learning culture with quality improvements designed and implemented to prevent future harm. This should ultimately be the judge of PSIRF’s success.

Poor behaviour and a corrosive blame culture

It is vital that organisations have an open and fair culture that enables patient safety issues to be raised, discussed and addressed. However, the presence of a blame culture, which results in people covering up errors that lead to avoidable harm rather than report them, comes up as a consistent theme in major patient safety scandals. This has been highlighted in the Mid-Staffordshire Inquiry in 2013, the Independent Medicines and Medical Devices Safety Review in 2020 and most recently in the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust.[12] [13] [3]

This is also a key concern in the East Kent Maternity services investigation. The report notes that a poor culture existed between obstetricians and midwives at the Trust, that there was a fear of speaking up about patient safety issues, a reluctance to listen to staff concerns and a bullying and blame culture when things went wrong. It appears that some of these issues were recognised internally at the Trust, but that efforts to tackle this proved ineffective:

“The Panel was told that there were “about three” cultural change programmes at the Trust that failed because of a lack of direction and leadership, and that the Trust paid lip service to cultural change but this was not sufficient. There was not enough commitment or engagement from leaders of the organisation.”[1]

“A consultant told the Panel: “The Trust thinks if you send someone on a three-day training course in human factors, that their personality will change forever but that’s not going to happen.” Another clinician expressed having limited confidence in the behaviour and competence of certain obstetricians.”[1]

Poor behaviour was not restricted to clinicians but also seen at senior leadership and governance levels too:

“The Panel further heard of poor behaviours of non-executive directors at the Trust Quality and Safety Committee: “The behaviour of the non-executive directors was appalling, rude, bullying. It was shameful.”[1]

In our report published earlier this year, Mind the implementation gap: The persistence of avoidable harm in the NHS, we highlighted that despite similar issues of blame culture coming up in multiple patient safety scandals over the past 20 years, currently the NHS still only has an outline of proposed activity to tackle this problem.[14]

The importance of having a just culture that supports patient safety is highlighted as a key aim of the NHS Patient Safety Strategy, and since the publication of the East Kent report the National Patient Safety Team has recently published new examples of good practice in this area.[15] However, three years into the Strategy we are yet to see more specific and robust measures proposed to address this. For instance, there are no specific proposals around organisations publishing and reporting on goals to change culture or steps for intervention when poor behaviours are identified.

This is not an issue limited to Trusts with serious patient safety scandals. The results of the NHS Staff Survey over the last three years show that too many staff still do not feel safe to speak up about errors, patient safety incidents and near misses.[16] [17] [18]

Disappointingly, this report makes no recommendations on this issue, perhaps considering it beyond the scope of the investigation. However, Patient Safety Learning believes that this is a theme that must be considered a high priority in the DHSC’s response to this report.

Lack of effective leadership for patient safety

Issues around organisational culture, as highlighted above, are interlinked with the importance of leadership for patient safety. Good leadership can drive patient safety performance, support learning from unsafe care and put in place clear governance processes to enable this. It is another of the six foundations of safer care identified in our report, A Blueprint for Action.

The East Kent Maternity services investigation consistently highlights a failure at a leadership level to identify and prevent avoidable harm to patients and deaths at the Trust, including:

•  Governance structures that were “not sufficiently robust to allow assurance from ward to Board”.[1]
• An impression by regulators that the Trust did not actively look for problems and issues to be resolved but waited for them to be pointed out.
• Poor Board relationships between the executive and non-executive directors.
• Lack of external benchmarking of performance and serious incidents.

The report makes two specific recommendations in relation to these issues:

1. Trusts be required to review their approach to reputation management and to ensuring there is proper representation of maternity care on their boards.
2. NHS England reconsider its approach to poorly performing trusts, with particular reference to leadership.

We support both these recommendations. However, we also believe that further urgent action is needed by the DHSC and NHS in relation to the report’s leadership findings, which have much in common with other recent inquiries and reports into serious patient safety failings.

We believe that there needs to be a more effective leadership and governance for patient safety in both the NHS and independent sector. There should be high standards and behaviours set for our leaders and they should be supported by specialist patient safety, organisational development and governance experts. As with the other key themes considered here, this is not a blank slate that requires new research and analysis. A useful starting point would be for the DHSC and NHS England to revisit the recommendations of the review of the Fit and Proper Person Test by Tom Kark QC and Jane Russell, published in 2019, which in its first recommendation called for:

“All directors (executive, non-executive and interim) should meet specified standards of competence to sit on the board of any health providing organisation. Where necessary, training should be available.”[19]

Organisations also need clear and published goals for patient safety with Board focus and effective oversight on reducing patient harm. A key part of our work around the development of patient safety standards for healthcare organisations is focused on strengthening patient safety leadership and governance in organisations as an integral part of a safety management systems approach (read more about this in the next section).

Absence of an effective regulatory framework

The East Kent Maternity services investigation gives a significant amount of attention to the Trust’s relationship with regulators during this period. The picture it paints is one of a system failing to act quickly or effectively in response to serious patient safety concerns, stating:

“We have found that the Trust was faced with a bewildering array of regulatory and supervisory bodies, but the system as a whole failed to identify the shortcomings early enough and clearly enough to ensure that real improvement followed.”[1]

The Trust was overseen by a range of different organisations, including:

• Care Quality Commission
• General Medical Council
• Its local Clinical Commissioning Group
• Healthcare Safety Investigation Branch
• Monitor (former NHS regulator whose functions are now part of NHS England)
• NHS England
• Nursing and Midwifery Council
• Royal College of Obstetricians and Gynaecologists
• Royal College of Midwives

The report suggested that “the plethora of regulators and others served to deflect the Trust into managing those relationships and away from its own responsibility”.[1]

As with the other themes highlighted in this article, these concerns about the effectiveness of the regulatory framework are not a new issue. In a 2018 report, Opening the door to change, the CQC described the current system as “confused and complex, with no clear understanding of how it is organised and who is responsible for what”.[20] Similar issues have also been highlighted in reports and inquiries such as the independent inquiry into the issues raised by Paterson and the Independent Medicines and Medical Devices Safety Review.[21] [3]

The Professional Standards Authority for Health and Social Care (PSA) have also recently discussed this in their report Safer Care for All, stating:

“Large-scale failures of care still occur frequently, and inquiries and reviews highlight similar themes and issues, with the system seemingly unable to prevent their recurrence. Each body looks at the problems principally through the lens of its own remit, often prejudging the nature of the solutions as a result. We need a new framework focused on safety that spans organisational and sectoral boundaries.”[22]

The East Kent report makes no specific recommendations about these system-level failures. However, Patient Safety Learning believes this is another issue the DHSC must consider as part of their response to this report. We need a joined-up and effective regulatory framework for patient safety that identifies problems at an early stage and facilitates and coordinates interventions and improvements.

Report recommendations

Now turning to the East Kent Report’s recommendations, in his introduction Dr Bill Kirkup states that he has opted not to make a series of specific policy recommendations. Setting out the rationale for this, the report states:

“NHS trusts already have many recommendations and action plans resulting from previous initiatives and investigations, and we have no desire to add to their burden with further detailed recommendations that would inevitably repeat those made previously, or conflict with them, or both. We take those previous recommendations and the resulting policy initiatives as a given."[1]

Instead, it sets out four broad areas describing the deep-rooted reform required to address the issues highlighted in the report. These are summarised below:

1. Creating a Task Force to drive the introduction of valid maternity and neonatal outcome measures for mandatory national use.
2. Reports to be commissioned on how compassionate care can best be embedded into practice and sustained through lifelong learning, alongside commissioning reports considering the oversight of clinicians, with national agreed standards of professional behaviour and sanctions for non-compliance.
3. Reports to be commissioned on how teamworking in maternity and neonatal care can be improved and how this can be supported in the employment and training of junior doctors.
4. Considering a new Government bill which would place a duty on public bodies not to deny, deflect or conceal information from families and other bodies. Alongside this, Trusts should be required to review their approach to reputation management, ensure there is maternity care representation on their Boards and for NHS England to reconsider its approach to poorly performing Trusts.

Action needed for a systems approach to patient safety

We support these recommendations, but also note the concern highlighted by Dr Kirkup about the effectiveness of inquiry recommendations in reducing avoidable harm. He states that:

“… this approach has been tried by almost every investigation in the five decades since the Inquiry into Ely Hospital, Cardiff, in 1967–69, and it does not work. At least, it does not work in preventing the recurrence of remarkably similar sets of problems in other places.”[1]

We concur with the disheartening sentiment. As set out in our report earlier this year, Mind the implementation gap, such recommendations are often eagerly received, with associated commitments to learn lessons from the past, but their implementation remains inadequate and patchy and their impact left unmonitored and often unevaluated.

However, as we make clear in this article, there are several overarching patient safety themes which the East Kent Maternity service investigation raises, in common with previous patient safety inquiries and reports, where there is a clear need for action. Some of these are not covered by the East Kent report’s recommendations.

Given that these are system-wide issues, not specific to one specialism or type of trust, we believe that the DHSC response to this report needs to consider these in their wider context, and account for the broader trends from reports and inquiries from the last 20 years. We need a holistic and joined up approach to these issues – not simply another commitment to ‘learn lessons’ without the necessary follow through.

As recently discussed in more detail in an interview with Keith Conradi on the hub, a key element of this is learning from other high-risk industries and moving towards the creation of a safety management system in healthcare, which he describes as follows:

“The basics of any safety management system is to have safety objectives, so you set out what you want to achieve. This requires assessment of the hazards and risks and the mitigation to those risks and these need to be transparent. You need an assurance process that constantly monitors the safety performance of the organisation and investigates incidents when they occur. This in turn will drive learning which will further improve safety and crucially embed a safety culture amongst all staff. All of this needs to be recognised at Board level, continually stretching the organisation’s safety objectives."[23]

While the NHS Patient Safety Strategy talks about moving towards “a patient safety system, across all settings of care”, in our view there is currently no overlapping approach to this and this needs to be urgently addressed.[9]

At Patient Safety Learning we believe that the persistence of avoidable harm is the result of our failure to address complex systemic causes. In our report A Blueprint for Action we identify six foundations of safer care for patients and practical actions to address them.[8] Central to this is the need for a transformation in our approach to patient safety, ensuring that this is treated as a core purpose of health and social care, not one of several competing strategic priorities to be traded off against each other.

Patient safety needs to be seen as everyone’s responsibility, from the DHSC, policy makers, patient safety experts, system and professional regulators, leaders, those developing and providing guidance on good practice, academics and to individual healthcare professionals. We need to operate as an effective Safety Management System with everyone working in partnership, aligned with patient safety at the core.

References

1. Independent Investigation into East Kent Maternity Services, Maternity and neonatal services in East Kent – the Report of the Independent Investigation, 19 October 2022.
2. Dr Bill Kirkup CBE, The Report of the Morecambe Bay Investigation, March 2015.
3. Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Findings, conclusions and essential actions from the independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust, 30 March 2022.
4. Sands and Tommy’s Joint Policy Unit, Responding to the independent report on East Kent maternity and neonatal services, 19 October 2022.
5. Sands and Tommy’s Joint Policy Unit, We need a renewed approach to improving the safety of maternity services, 21 October 2022.
6. Baby Lifeline, The East Kent Report: In summary, 19 October 2022.
7. Birthrights, Birthrights responds to the independent investigation into East Kent maternity services, 2 November 2022.
8. Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019.
9. NHS England, The NHS Patient Safety Strategy, 2019.
10. NHS England and NHS Improvement, Framework for involving patients in patient safety, 29 June 2021.
11. NHS England, Patient Safety Incident Response Framework, Last Accessed 8 November 2022.
12. The Mid Staffordshire NHS Foundation Trust Public Inquiry, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, 6 February 2013.
13. The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020.
14. Patient Safety Learning, Mind the implementation gap: The persistence of avoidable harm in the NHS, April 2022.
15. NHS England, Safety Culture: learning from best practice, 15 November 2022.
16. Patient Safety Learning, Results of the NHS Staff Survey 2019, 18 February 2020.
17. Patient Safety Learning, Tackling the blame culture? NHS Staff Survey Results 2020, 22 March 2021.
18. Patient Safety Learning, Safe to Speak up? NHS Staff Survey Results 2021, 31 March 2022.
19. Tom Kark QC and Jane Russell, A review of the Fit and Proper Person Test, 6 February 2019.
20. CQC, Opening the door to change: NHS safety culture and the need for transformation, 2018.
21. The Right Reverend Graham Jones, Report of the Independent Inquiry into the Issues raised by Paterson, 2020.
22. PSA, Safer care for all – solutions from professional regulation and beyond, 6 September 2022.
23. Patient Safety Learning, Why healthcare needs to operate as a safety management system: In conversation with Keith Conradi, 24 October 2022

The independent investigation into East Kent Hospitals NHS Foundation Trust has today published a report setting out its findings and key areas where action is needed to improve patient safety in maternity and neonatal services.[1]

The investigation was formally commissioned in February 2020. Its aim was to assess the systems and processes used by the Trust to monitor compliance and improve quality within the maternity and neonatal care pathway, evaluate their approach to risk management and implementing lessons learnt, and to assess the governance arrangements that oversee the delivery of these services.[2]

This is yet another devastating report into avoidable harm in healthcare, stating that having examined these services between 2009 to 2020 it found:

“Over that period, those responsible for the services too often provided clinical care that was suboptimal and led to significant harm, failed to listen to the families involved, and acted in ways which made the experience of families unacceptably and distressingly poor.”

The report highlights several underlying issues which contributed to the cases of avoidable harm it considered, many of which we see featured time and again in other public inquiries into unsafe care:

• Failures of teamworking.
• Failures in professionalism.
• Failures in compassion.
•  Failures to listen.
• Failures after safety incidents.
• Failures in the Trust’s response, including at Trust Board level.

Another recurring theme highlighted by this report is the failure at a regulatory level to identify these problems, and once identified to take action to address them. It states that:

“We have found that the Trust was faced with a bewildering array of regulatory and supervisory bodies, but the system as a whole failed to identify the shortcomings early enough and clearly enough to ensure that real improvement followed.”

The report identifies four key areas where action is needed to improve patient safety, with accompanying recommendations in each of these:

1.    Monitoring safe performance – finding signals among noise

2.    Standards of clinical behaviour – technical care is not enough

3.    Flawed teamworking – pulling in different directions

4.    Organisational behaviour – looking good while doing badly

Commenting on the publication of today’s report, Patient Safety Learning Chief Executive Helen Hughes said:

“This is another shocking report into patient safety failings in maternity and neonatal services and our thoughts are with all the patients and families affected by this at this incredibly difficult time. It is thanks to their persistence and tenacity in raising these concerns that this investigation has taken place.

The report makes a harrowing read, highlighting serious patient safety failures in the Trust. There were multiple missed opportunities to learn from avoidable harm and take action. Worse still, we see recurring themes from previous inquiries into patient safety issues such as a dismissal of patients views and concerns, defensive and toxic organisational culture and organisational leadership that doesn’t place patient safety as a core purpose.

We agree with Dr Kirkup’s analysis that this is not simply a “one off, isolated failure”. Over the past twenty years we have seen numerous inquiry reports published into serious patient safety failings, many of these focused on maternity care. Many of the previous inquiry report’s recommendations, years later, remain only partially implemented and serious avoidable harm continues to persist, with the same underlying themes coming up time and time again; themes of organisational and regulatory leadership, failure to learn and act upon that learning; failure to set standards for behaviours and hold people to account within a just culture. These are systemic failures.

Patient Safety Learning believes that, in considering their response to this review, the Department of Health and Social Care and the NHS must consider these findings within the wider context of these other reports into serious patient safety failings. We cannot simply deal with these issues in isolation. We will only make healthcare safe for patients when we tackle the underlying causes of avoidable harm. We need a transformation in our approach to patient safety, making this a core purpose of health and social care, not one of several competing strategic priorities to be traded off against each other.”

References

1. Independent Investigation into East Kent Maternity Services, Maternity and neonatal services in East Kent – the Report of the Independent Investigation, 19 October 2022.
2. Independent Investigation into East Kent Maternity Services, Terms of Reference, Last Accessed 19 October 2022

• Describing how those responsible for the provision of maternity services failed to ensure the safety of women and babies, leading to repeated suboptimal care and poor outcomes – in many cases disastrous.
• Highlighting an unacceptable lack of compassion and kindness, impacting heavily on women and families both as part of their care and afterwards, when they sought answers to understand what had gone wrong.
• Delineating grossly flawed teamworking among and between midwifery and medical staff, and an organisational response characterised by internal and external denial with many missed opportunities to investigate and correct devastating failings.

Key areas for action

The report has not sought to make multiple detailed recommendations, with its author noting that NHS trusts already have many maternity safety recommendations and action plans resulting from previous initiatives and investigations. Instead, it identifies identify four broad areas for action based firmly on its findings but with much wider applicability:

1.    Monitoring safe performance – finding signals among noise

Recommendation:

• 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.

 2.    Standards of clinical behaviour – technical care is not enough

 Recommendations:

• 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.

3.    Flawed teamworking – pulling in different directions

Recommendations:

• 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.

 4.    Organisational behaviour – looking good while doing badly

 Recommendations:

• 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.
• NHSE reconsider its approach to poorly performing trusts, with particular reference to leadership.

East Kent Hospitals University NHS Foundation Trust

The report also makes one recommendation specific to the Trust:

• The Trust 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.

Related reading

• East Kent Hospitals maternity services: HSIB summary report (7 April 2020)
• Prevention of Future Deaths Report: Harry Richford (3 February 2020)

Following receipt of a letter by the Chief Executive from two complainants in July 2020 concerning Mr Ben Reid (the former Chair of the Trust), Ms Fiona Scolding KC was commissioned by the Trust to carry out an independent investigation with regard to whether or not the issues raised in that letter gave rise to matters which engage the Fit and Proper Persons Regulations (FPPR), such that Mr Reid’s actions meant that he should no longer be considered to be a fit and proper person in accordance with the FPPR.

In her report, Ms Scolding concludes that the complaints against Mr Reid do not amount to matters which would be considered to meet the test of “unfitness” set out in the FPPR. She concludes that mistakes were made and that, although the actions of Mr Reid were not always correct, they did not meet the threshold of “serious” mismanagement by way of deliberate activity or standards which fall significantly below the level of the competent Chair.

Ms Scolding's findings and recommendations can be read in the Appendices of the Board paper.