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  • 'Reading the signals': Maternity and neonatal services in East Kent – the Report of the Independent Investigation (19 October 2022)

    Patient Safety Learning
    • UK
    • Investigations
    • Pre-existing
    • Original author
    • No
    • Dr Bill Kirkup
    • 19/10/22
    • Health and care staff, Patient safety leads


    In February 2020 the UK Government commissioned Dr Bill Kirkup to undertake a review into maternity and neonatal care services between 2009 and 2020 in two hospitals, the Queen Elizabeth The Queen Mother Hospital (QEQM) at Margate and the William Harvey Hospital (WHH) in Ashford. Both these services fall under the East Kent Hospitals NHS Foundation Trust.

    The report found that over this period those responsible for these 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. It identifies four key areas for action which must be addressed to improve patient safety in maternity and neonatal care services.


    This report sets out the findings of the Panel’s Investigation of maternity services at East Kent Hospitals University NHS Foundation Trust, by:

    • 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


    • 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


    • 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


    • 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


    • 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

    'Reading the signals': Maternity and neonatal services in East Kent – the Report of the Independent Investigation (19 October 2022) https://www.gov.uk/government/publications/maternity-and-neonatal-services-in-east-kent-reading-the-signals-report
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