Government response to ‘Reading the signals: maternity and neonatal services in East Kent - the report of the independent investigation’ (20 July 2023)

Summary

This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the Independent Investigation into East Kent Maternity services.

Content

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)