The Independent Investigation into East Kent Maternity Services has published its report on the care that 202 families received between 2009 and 2020 from the maternity services at two hospitals run by East Kent Hospitals University NHS Foundation Trust. The inquiry concluded that those who were responsible for providing maternity services at the Queen Elizabeth The Queen Mother Hospital (QEQM) in Margate and the William Harvey Hospital (WHH) in Ashford failed to ensure the safety of women and babies, resulting in repeated poor care and disastrous outcomes for mothers and babies. The suffering of these women and their families was increased by an unacceptable lack of compassion and kindness during their care and when they later sought answers to try to understand what had gone wrong. Substandard clinical treatment led to the avoidable death of at least 45 babies and brain injury to 12 more, and death or injury to 23 mothers. However, responsibility for this catastrophe lies with the trust’s leadership which persistently failed to accept warnings and address problems such as ‘grossly flawed teamworking’ between midwives and doctors, dangerously unsupportive behaviour by consultants, and a trust board which responded to incidents, complaints or external scrutiny with denial and defensiveness, missing opportunities to investigate and correct its devastating failings. The report warns that the NHS can no longer pretend that maternity scandals like East Kent are one-off catastrophic events which will never happen again. For that reason, it does not issue further specific recommendations to add to those already made by other inquiries which have failed to bring about change. Instead, it warns that unless the NHS gets serious about identifying poorly performing units, giving care with compassion and kindness, teamworking with a common purpose and responding to challenge with honesty, similar tragedies will happen elsewhere. What is the background to the East Kent Maternity Inquiry? One of the many shocking aspects of this maternity scandal, is that the problems at East Kent’s two maternity units which led to the inquiry had been brought to the trust board’s attention by regulators and professional bodies on many occasions. We talked about some of these incidents when the inquiry began in a previous post, which you can read here. The inquiry report describes the trust’s refusal to accept what they were being told and to learn from these events as missed opportunities which could have prevented further harm to mothers and babies. However, this also illustrates how a deeply embedded NHS hospital culture of defensiveness and denial can resist change and avoid sanction even under the regulatory and professional scrutiny of the Royal College of Obstetricians and Gynaecologists (RCOG), the Healthcare Safety Investigation Branch (HSIB) and the Care Quality Commission (CQC). In 2015, the trust’s own medical director invited RCOG to review the trust’s maternity services, owing to concerns about poor culture, teamwork, lack of consultant responsiveness and attendance, and other maternity safety issues. RCOG’s report in early 2016 highlighted serious concerns, including lack of supervision and support by consultants and leaving junior doctors and midwives to manage complicated births, and warned the trust that patient safety would be at risk unless it took action to improve its maternity services. The trust board refused to respond to RCOG pending an inspection from the CQC, which had rated the Trust inadequate and placed it into special measures in 2014. However, the trust then withheld RCOG’s report from the CQC which lifted the special measures in 2017. In December 2018, HSIB raised its concerns about repeated maternity safety themes at the trust after investigating 19 babies with HIE, and the deaths of three newborn babies and two mothers. The trust failed to cooperate with HSIB which eventually escalated its concerns directly to the CQC. In 2020, after The Independent reported on the growing maternity scandal, the government finally announced that an independent investigation would look into maternity services at the trust. Terms of reference for the inquiry were placed before Parliament in March 2021, and Dr Bill Kirkup CBE was appointed to lead the investigation. Dr Kirkup is a former obstetrician who is highly respected for his work on previous high-profile inquiries into NHS care scandals, such as Morecambe Bay Maternity Services, Children’s Heart Surgery in Oxford, Jimmy Savile’s involvement at Broadmoor Hospital, and the Hillsborough Independent Panel. Key findings from the Kirkup Inquiry into maternity services at East Kent Hospitals University NHS Foundation Trust The inquiry found that those responsible for maternity services too often provided poor clinical care which led to significant harm. They failed to listen to families and acted in unacceptable ways which added to the families’ distress. The trust board and senior managers were made aware of these individual and collective behaviours in a series of reports throughout 2009 to 2020. The report emphasises that honest clinical errors will always occur in clinical practise but should be recognised, reported and learned from. Accountability for the scale of this tragedy lies with the trust’s leadership and senior management whose refusal to acknowledge and tackle these issues lay at the root of the pattern of recurring harm. In relation to clinical outcomes the inquiry panel found that if correct care had been given, the outcomes could have been different for: 97 (48%) of the 202 cases; 45 (69%) of the baby deaths; 12 (70.6%) of the 17 babies with HIE brain injury and/or cerebral palsy from perinatal hypoxia; 23 (71.9%) of the maternal injuries or deaths. There was no evidence of improvements in outcomes or suboptimal care from 2009 to 2020. The inquiry panel believed that these numbers are minimum estimates of the frequency of harm over the period but they limited their investigation to the families who volunteered. The report found repeated failure by staff to listen to women when they raised concerns, questioned or challenged decisions that were made about their care. In addition to clinical care, these families experienced additional and ongoing suffering as a result of: lack of kindness and compassion, including indifference to their pain, loss or needs; unprofessional conduct, rudeness, exposure to backbiting and blaming between colleagues, and insensitive handling caused by failure to pass on key information at team handover, such as when an unborn baby was known to have died; being excluded or ignored during and after serious events, including failure to comply with the duty of candour; leaving women and families feeling to blame for the injury, and failing to give reasons why things had gone wrong; The inquiry identified problems at every level, including during the women’s care in the maternity units, the trust board’s refusal to respond, acknowledge incidents and learn from lessons, and their denial and defensiveness when under scrutiny from professional and safety regulators. Within the maternity units, failures of teamworking, professionalism, compassion and listening played a greater role in the harm than lack of resources, staffing, infrastructure and split site/geographical causes. The culture was one of tribalism, bullying, and a ‘downright dangerous’ refusal by consultants to attend or support experienced or junior staff who were left to manage (and be accountable for ) high risk clinical situations for which they were often untrained. The trust board responded to incidents by blaming (often junior) individual staff members, and exercised no control over consultants who refused to change their unacceptable behaviour. They sacked and replaced managers who challenged poor behaviour, leaving in place those whose behaviour was part of the problem or who condoned rather than questioned it. Their many action plans reflected what the inquiry described as ‘an imagined world with fewer problems’. They falsely reassured themselves that the trust was not alone in its problems and was the real victim of critical reports. The report says that even now, East Kent still hasn’t fully acknowledged the full extent and nature of its problems. The inquiry concludes that if further maternity tragedies are to be avoided, the NHS must tackle its embedded, deep-rooted failure to identify poorly performing units, give care with compassion and kindness, teamwork with a common purpose, and respond to challenge with honesty. The key to ‘detecting the next unit that begins to veer off the rails before widespread harm has been caused, and before it has had to be identified by families who have suffered unnecessarily’ is for the NHS to ‘become serious about measuring outcomes in maternity services’. The report’s recommendations call for system level action from the NHS, professional bodies and government to address these issues, including drafting legislation which would ‘place a duty on public bodies not to deny, deflect and conceal information from families and other bodies.’ In dealing with East Kent, the report recommends that ‘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.’ Helping families after injury and loss from negligent maternity care Every birth that, through error, ends in serious injury or death is a tragedy which should not be repeated. Multiple tragedies, such as those experienced by the families who placed their trust in maternity services at East Kent, signal deeper problems which must be rooted out at national level. We welcome the openness, honesty and rigour of Dr Kirkup’s inquiry, its fearless approach to accountability, and the unequivocal call for change that runs through the entire report. We are deeply saddened by the suffering that these brave families have experienced, and the harm suffered by so many others, including our own clients’ experiences of negligent maternity and neonatal care. The need for change has never been clearer or more urgent, and until it takes place, Boyes Turner remains committed to helping families of mothers and children who have suffered avoidable harm recover their full entitlement to compensation. If you or your child have been injured as a result of negligent maternity care, you can talk to one of our experienced solicitors, free and confidentially, for advice about dealing with HSIB or NHS Resolution, or to find out more about how we can help you claim your right to compensation, by emailing email@example.com or call 0118 952 7201.