Responding to independent report on East Kent maternity and neonatal services

An independent investigation into East Kent Maternity Services, led by Dr Bill Kirkup, was published on Wednesday 19 October, highlighting serious failings, missed opportunities to improve, and the devastating impact this has had on families.

Tommy’s, working in partnership with Sands, is urging the NHS to commit to learning, transparency and culture change. Bereaved families should not have to fight to highlight systemic failings in maternity services before action is taken.

We are devastated to read today’s report by Dr Kirkup and team which has concluded up to 45 babies might have survived if they had received better care at East Kent NHS Hospitals Trust. The report reviewed births between 2009-2020 at two hospitals in Margate and Ashford.

The report exposes serious failings and the devastating impact they have had on families. It makes clear that families were faced with a culture of denial, deflection and concealment when seeking answers about their care – worsening the harm caused and preventing opportunities to learn.

Following shortly after the publication of the Ockenden review in March, these messages are too familiar and expose unacceptable disparities in maternity services across the UK. 

In themes which are sadly familiar, the East Kent investigation exposed "gross failures" in teamworking across the Trust's maternity services, alongside failures in professionalism among staff, a lack of compassion and kindness from staff toward families, and staff repeatedly failing to listen to families. While problems among midwifery staff and the obstetric staff were known, the Trust failed to respond at board level to address issues. 

The report also criticises the system of regulatory and supervisory bodies as a whole for failing to identify shortcomings early enough and clearly enough to ensure that real improvement followed. 

While this report makes for disturbing reading, it is important to note that most maternity care in the UK is safe. However, as these two independent reports, and a 2022 Care Quality Commission report note, it is critical that hospital trusts continuously look at ways to improve maternity care and safety so women and babies are not put at avoidable risk of harm.  

The East Kent report identifies 4 areas for action. The NHS could be much better at:

1.    identifying poorly performing units, 
2.    giving care with compassion and kindness, 
3.    teamworking with a common purpose, 
4.    and at responding to challenge with honesty.

Robert Wilson, Head of the Sands & Tommy’s Joint Policy Unit, says: 

“This is the second major report into serious failings in maternity services in England published this year. A review of maternity services at Nottingham University Hospitals NHS Trust is also ongoing.

“These reports contain similar themes which are relevant across the NHS. It’s clear that a much more comprehensive, joined-up approach to improving maternity and neonatal services as a result of these reviews is needed. 

“It cannot continue to be up to bereaved families to highlight systemic failings in maternity services before action is taken.

“The NHS must commit to implementing a just and learning culture, where services are open and transparent when things go wrong, with systems locally and nationally that support this approach. This needs to be supported with adequate funding and workforce if we are going to make the UK the safest place in the world to have a baby.”

Kath Abrahams, Tommy’s Chief Executive, says:

“Our thoughts are with all families affected by the devastating failings in East Kent, many of whom have fought for years through their grief in search of answers and accountability.  

“Action must be immediate in overhauling maternity services at a local level and the learnings from this review taken onboard nationally too. Today’s report makes clear recommendations for change and shows that everyone involved in providing maternity care have a role to play in reducing the unacceptable numbers of avoidable deaths.”