Patient Safety Learning: Initial response to the East Kent Maternity Inquiry Report (19 October 2022)

Summary

In this short blog, Patient Safety Learning sets out its initial response to the publication of the report of the independent investigation into maternity and neonatal services at the East Kent Hospitals NHS Foundation Trust.

Content

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