East Kent Maternity Services: Independent Investigation

Monday 24th October 2022 Lords Chamber

Statement

The following Statement was made in the House of Commons on Thursday 20 October.

“With permission, Mr Speaker, I will make a Statement on the review into East Kent maternity services.

Few things could be as tragic as the death of a child, yet knowing that that death was ‘wholly avoidable’ comes with its own unimaginable pain. It is thanks to the tireless efforts, courage and determination of families in East Kent that we have been able to shine a light on maternity failings in East Kent Hospitals University Trust. Dr Bill Kirkup’s report, published yesterday, contains some stark and upsetting findings. From examining over 200 births in that trust between 2009 and 2020, he found that, had care been given at nationally recognised standards, 45 babies might not have lost their lives, and many more families might not have experienced such distress at what should have been their time of joy. He also found a toxic culture within the trust, with a

‘disturbing lack of kindness and compassion’

and victims’ families even blamed for their devastating losses. Before I say more, Mr Speaker, I want to say this: I am profoundly sorry to all the families affected. This should never have happened, and we will work tirelessly to put it right.

With the report having been published just yesterday, I am sure honourable Members will understand our need to carefully consider all of its details. I will be reviewing all the recommendations, and will issue a full response once I have had time to consider them. However, given the gravity of what the report reveals, I felt it was important to come to the House today and update colleagues on the steps we are already taking to improve maternity services in East Kent and across the country.

The report itself is a litany of failure that makes for very difficult reading. It details failures of team working, failures of professionalism, failures of compassion, failures to listen, failures after safety incidents and ultimately a failure of leadership. The review heard about women and family members feeling patronised, ignored or told off, with one woman hearing from a doctor:

‘Some parents just aren’t supposed to have children.’

Some people felt they were unimportant, or too much trouble. One woman was reportedly told by a staff member that they were sorry for her loss, but that her baby was dead, and that there were other babies who were still living who needed attending to. These kinds of failures showed up at every level of patient care, with no discernible improvement over the whole timeframe of the review. The trust failed to read the signals and missed every opportunity to put things right.

These are difficult things to hear, and especially hard because I know that so many of us have experienced for ourselves the brilliant care that NHS maternity services can offer. We must take nothing away from the hundreds of thousands of incredible people working day and night in maternity services across the country, yet we cannot pretend that the story of East Kent is a one-off. Reviews from Morecambe Bay and Shrewsbury and Telford paint a more disturbing picture. While they may be some of the most extreme examples—and we must hope that they are—they are certainly not isolated incidents. Colleagues will know that, just last month, Donna Ockenden began her independent review into maternity services at Nottingham University Hospitals NHS Trust.

We entrust the NHS with our care when we are at our most vulnerable. Everyone has the right to expect the same high-quality care, no matter who they are or where they live. We are already taking a number of steps to improve the quality of maternity care in East Kent and across the country. An intensive programme of maternity support was put in place at East Kent Hospitals University NHS Foundation Trust in September 2019, overseen by NHS England, the Kent and Medway integrated care system and the trust’s board. The trust has been allocated a maternity improvement adviser and an obstetric improvement adviser. We will also continue to ensure the highest standards at national level.

I am grateful to Dr Kirkup for the extensive recommendations in his report, but it is vital that they are not viewed in isolation. As Dr Kirkup said, since his Morecambe Bay investigation in 2015,

‘maternity services have been the subject of more significant policy initiatives than any other service’,

so his recommendations must be considered alongside existing work to improve maternity outcomes.

First, there is our independent working group. The group is one of the key immediate and essential actions from the Ockenden review and has begun its important work. The group, chaired by the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists, is advising the maternity transformation programme in England on how it can take forward the findings of both the Ockenden and the Kirkup reports. Next, our new maternity quality surveillance framework is a vital tool for proactively identifying problems in trusts, so that they can get support before serious issues arise. In March 2022, NHS England announced a £127 million funding boost for maternity services across England, to help ensure safer and more personalised care for women and their babies. Even with that essential work, we recognise that there is still a long way to go and much more work to be done to put things right.

In closing, I want to thank Dr Kirkup and his team. His experience has been invaluable, and I know that his approach of putting families first has been welcomed. I also know that hearing the accounts of families has been a harrowing experience at times, yet, as he said, it is difficult to imagine just how much harder it was for the families as they relived some of their darkest days. I am sure the whole House will join me in paying tribute to those families, whose tireless determination to find the truth and tell their stories has brought us to this important point. Nothing we do can bring back the children they have lost or fill the tragic void of a life never lived, but now we know their stories, we will listen, learn and act, so that no other family should ever experience such pain. I commend this statement to the House.”

20:08

[Baroness Merron (Lab)]

My Lords, I start by thanking Dr Bill Kirkup and his team for bringing together a report of harrowing events. This litany of failures makes for very difficult reading, and it marks another landmark for a further group of families fighting for justice who should not have had to do so. Forty-five babies could have survived had they received care at the nationally recognised standards. I am sure that the thoughts of the whole House are with the bereaved families at this extremely painful time.

This is, regrettably, yet another example of women’s voices being ignored and silenced, to the extent that some were told that they were to blame for the deaths of their babies. At a time when women are at their most vulnerable, they were let down by the very people who they were relying on to keep them safe. However, this is not a one-off: East Kent is the latest in a long line of maternity scandals, including at Shrewsbury and Telford Hospital NHS Trust and Morecambe Bay, while the upcoming review of services in Nottingham is expected to be highly critical. Dr Kirkup said that avoidable deaths happened because recommendations that had been made following reports into other scandals had not been implemented. I would be grateful if the Minister could respond to this.

We know that no woman should ever have to face going into hospital to give birth, not knowing whether she and her baby will come out alive. Those who allowed this culture of neglect and what was referred to in the report as a disturbing

“lack of kindness and compassion”

to take root must be held accountable. Can the Minister tell your Lordships’ House how this may happen?

It is shocking that there is a pattern of avoidable harm in maternity units across the country. Half the maternity units in England are failing to meet safety standards. Pregnant women were turned away from maternity wards more than 400 times last year. One in four women are unable to get the help that they need when in labour. The Government need to fully accept all the recommendations in Dr Kirkup’s review without delay. I hope the Minister will today confirm that this is the case.

In the wake of the Ockenden review, the former Health Secretary announced additional funding for maternity services to help deliver the reform that is clearly needed. Can the Minister tell your Lordships’ House how that funding has been spent and how its impact will be measured? Indeed, it would be very helpful if the Minister could bring a further report to this House on progress in the improvement of maternity services.

Underpinning the issues in maternity care and across the NHS is, of course, the workforce. But more midwives are leaving the profession than are joining it and there is now a shortage of some 2,000 midwives in England alone. Can the Minister indicate where we can find the workforce plan to get the staff needed to provide good and safe care in the short, medium and long term? It is evident that the Government must provide the staff that maternity services desperately need to provide safe care across the health service.

I am sure we were all concerned to read the Care Quality Commission’s report published just two days after Dr Kirkup’s report. It also makes sobering reading. It says that maternity services in England have deteriorated to their lowest level, services are worsening and, time and again, there are issues with the leadership and culture in maternity units.

The CQC’s chief executive said that the failings were systemic in the NHS, with two in five maternity services now ranked as requiring improvement or inadequate. This is a wholly unacceptable situation. Does the Minister share the view of the regulator that the issues in maternity services are a “national challenge”?

This CQC report shows that there has been a deterioration in maternity services overall and in relation to their safety, describing progress on improvement as “slow”. The proportion of maternity services ranked as inadequate or requiring improvement is, we see, the worst it has ever been. What actions will the Government take? Will the Minister be meeting the CQC urgently to discuss its findings? How will a major change in maternity services be brought about?

All that women and their loved ones ask for is to have confidence that they and their babies will be safe. This really is not much to ask. I hope the Government will provide the means to deliver this.

[Baroness Brinton (LD)]

My Lords, I want to start from these Benches by sending my deepest sympathies to the bereaved families and to say that we admire the parents for their campaigns over many years against the dreadful treatment by the east Kent hospitals trust for more than a decade. I echo the thanks and gratitude from the noble Baroness, Lady Merron, to Dr Kirkup and his team. Once again, he has risen to the challenge of providing a very clear picture of what has gone wrong at a hospital trust.

The trust failed to read the signals over an 11-year period. The Kirkup report puts this very bluntly and is exceptional in the way it uses evidence. Yes, there is the evidence of the voices of mothers and their families and the evidence from staff, but equally important is the use of data, especially the CESDI data from the Confidential Enquiry into Stillbirths and Deaths in Infancy. In the section headed “What happened to women and babies”, paragraph 1.16 says that

“we have not found that a single clinical shortcoming explains the outcomes. Nor should the pattern of repeated poor outcomes be attributed to individual clinical error, although clearly a failure to learn in the aftermath of obvious safety incidents has contributed to this repetition.”

This short paragraph encapsulates how failings have become cultural in the trust. Paragraph 1.19 says that

“we have found that the origins of the harm we have identified and set out in this Report lie in failures of teamworking, professionalism, compassion and listening.”

It is really worrying to have the report from the CQC of a few days ago, which echoed these exact points but more broadly across maternity services in England.

As has been mentioned, there is a wider problem. We know that. The reports on Morecambe Bay, Shrewsbury, Telford and now Nottingham, where Ms Ockenden is now working, show that systemic and cultural failures, especially with the complexity of regulators, are creating real problems. There is the idea that clinical staff will allow favouritism and the opposite of growing and supporting staff, while letting things fester and not caring to drag patients into their concerns.

Can the Minister outline the timescale for the independent working group report referred to in the Statement? The creation of the group is welcome; its main remit is to advise the maternity transformation programme in England—but by when? Is the work of the group revealing that other maternity services have problems, even if we do not know how severe they are or if they are as severe as East Kent?

In the section on the actions of the regulators on page 9, at paragraph 1.50, Dr Kirkup identified 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”.

It is good that it is reported that NHS England and Innovation sought to bring about improvements, but every other trust is also facing that same complexity of different regulators. Are the Government looking at the roles of regulators and how their competing demands can be streamlined to avoid this problem?

The Commons Minister said that she would review all the recommendations and provide a full response once she has had time to consider it. I think we all appreciate that the NHS has a very large workload at the moment, but can the Minister say roughly what timescale we are looking at?

One key problem in many maternity services is with the workforce, especially midwives. Although NHS England made an exceptional grant in March of £127 million as a boost for

“safer and more personalised care”,

can the Minister say—I echo the point made by the noble Baroness, Lady Merron, which he will not be surprised to hear—where the workforce plan is for the next decade for maternity services? A year’s extra money is not going to help with training the midwives of the future and ensuring that maternity units are professionally and adequately staffed.

Dr Kirkup also criticised NHS England for firing chairs and chief execs too frequently, indulging in a blame game that reinforced the culture happening inside East Kent. It is no longer good enough to say, once again, that this must never happen again. This is the third devastating report in under seven years, and another is now being prepared in Nottingham. What will the Government do in the next three months to ensure that further appalling practice will be uncovered and dealt with immediately?

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)]

Dr Kirkup’s report, published last week, contains some stark and upsetting findings. As mentioned, the report examined more than 200 births in east Kent between 2009 and 2020 and found that, had care been given at nationally recognised standards, 45 babies might not have lost their lives and many more families might not have experienced such distress at what should have been a time of joy. He also found a toxic culture in the trust, with a disturbing lack of kindness and compassion, and victims’ families even blamed for their devastating losses. The report underlines that the NHS needs to be better at identifying poorly performing units and at giving care with compassion and kindness, as well as team working with a common purpose and responding to challenge with honesty. I take all the findings and areas of concern extremely seriously.

I want to thank Dr Kirkup and his team; his experience has been invaluable and I know that his approach to putting families first has been welcomed. I also know that hearing the accounts of families has been a harrowing experience at times, yet, as he said, it is difficult to imagine just how hard it was for the families as they relived some of their darkest days. I am profoundly sorry to all the families who have suffered and continue to suffer from these tragedies. I pay tribute to the families who have come forward to assist the review; it is thanks to the tireless efforts, courage and determination of families in east Kent that we have been able to shine a light on maternity failings in East Kent Hospitals University NHS Foundation Trust.

Before directly addressing the recommendations, I want to put the tragic findings in the context of an improving service overall. Since 2010, stillbirths have declined by 19%, neonatal mortality over 24 weeks by 36% and maternal mortality by 17%. That is not to undermine the seriousness of the circumstances.

On the recommendations, I echo the comments already made. I know that it is top of Minister Johnson’s agenda in making sure that there are speedy, but also measured, responses. As part of that, I want to touch on some of the points made, particularly by the noble Baroness, Lady Brinton, about the use of data as part of the early warning indicators. I think we all agree that that is key to this area. This is exactly the work that the national maternity safety surveillance and concerns group was set up for: to make sure that there is methodical oversight in this area. It is in its power to recommend that people are put into the maternity safety support programme; 23 hospitals are currently in it and it is recommended that four have progressed enough to come out again, but another 10 have been identified that may need to be put into it.

It depends on how you look at it, and whether you take solace in these trusts being identified, or whether you are concerned about the number out there. Personally—I hope I echo the comments of all of us in the House—I believe it is much better that we identify them and deal with it, however uncomfortable that might be in the meantime. The lesson we have learned from these unfortunate cases, as recognised by the noble Baroness, Lady Merron, is that we have seen a failure of leadership and accountability here.

I am glad to see that, in responding, the trusts have been unequivocal in accepting unreservedly the failings on their part and have apologised wholeheartedly. As we know in these times, when dealing with these situations the first thing that has to happen is recognising that the problem exists.

I will need to write to the noble Baroness about the extra investment and how that spend is being allocated. It is very much on the agenda of Minister Johnson to look at that and at the improvements that have been made.

On the shortage of midwives, the picture as I understand it right now is that we have had a stable number of midwives—around 21,500—over the last four years. Within that, we do have the target, as mentioned, to increase it by 1,200, and that is part of the £95 million investment towards this. I accept that doing that is more than a one-year plan and needs to be part of a much larger picture.

I welcome the CQC focus on this area. It is something that we all agree needs to be an area of focus; if that makes for some uncomfortable findings then so be it. It is only when we understand those areas that we can really get on and make sure that we deal with them. I hope that we are looking to move on in these areas.

The Maternity Safety Support Programme is a force for good, and I am glad to say that, in East Kent, they have been working on the improvement plan as part of the support programme, and 65 of the 67 actions have now been completed, with the final two to be completed by the end of November. That is not to be complacent: that work should have been done a lot earlier, but I am glad to see it is being worked on now.

I have tried in these answers to respond to the questions, but I will follow up in any areas where I have not. In summary, I again thank and pay tribute to those families whose tireless determination to find the trust in telling their stories has brought us to this important point. The Government will be reviewing and considering all the recommendations from the report. We will listen, learn and act to ensure that no other family has to ever experience the same pain in the future.

20:27

[Baroness Gohir (CB)]

My Lords, I thank noble Lords for being patient with me, as I am still learning the rules. I draw attention to my interests in the register. Given the continuous maternity concerns raised in this and many other reports, including by women’s groups, is it time to have a maternity commissioner? As the noble Baroness, Lady Merron, mentioned, what needs to happen to ensure that we get that change? Could the answer be a maternity commissioner who is independent and who then holds the Government to account?

[Lord Markham (Con)]

The noble Baroness is right to say that it is clear that we have not got it right to date, as shown by the fact that these instances have come up. We are taking the right steps with the Maternity Safety Support Programme that we have put in place, and its ability to put trusts into special measures—as I say, that has already been done on 23 occasions and it is being considered for another 10. I believe we have got those early warning indicators in place now, and trusts are being held to account. At the same time, we have to be open, to make sure that we continue to look at and review this, to see whether it has sufficient teeth and, dare I say, intelligence to properly identify these areas. If it does not manage to do that, we must make sure we put in something else, in addition to what is there already.

[Baroness Cumberlege (Con)]

My Lords, I have had a very long interest in maternity services, and it seemed to me, on this occasion, that I could make a few comments. This report is truly remarkable. It is investigating the tragedies and failures, the lack of care, the divisive attitudes among professionals, and the lack of teamwork and much else. The report is really here partly due to the pressure of patients and the public, who wanted to bring to the attention of the Government the failures in East Kent.

I thank my noble friend for his report. The recommendations are different from the usual recommendations, in that they go much wider than just East Kent; they go across the country as a whole, and they are very important. On reading that report, has he any ideas about how to stimulate the doctors, nurses, midwives, obstetricians, managers and leaders not only in East Kent but across the country to take note of what it is saying? It very much affects not just them but parents, families, friends and childbearing women, and it is important that they have optimal care that is kinder, compassionate, more personal and safer. What action are the Government going to take, working with NHS England, because there are a lot of partners in this area of maternity? Will he ensure that the recommendations are not ignored—that they are not just put on a shelf and forgotten—and will he come back to Parliament within, say, four to six months to explain what progress has been made in implementing them in the four areas cited for action? I would very much welcome that, because I want to see this report implemented and not just put on another shelf.

[Lord Markham (Con)]

I thank my noble friend for her question; I know this is an area in which she has longstanding interest and expertise. She refers to embedding compassionate care and, perhaps like all of us, I am surprised to learn that, unfortunately, we may need training in this area; but I agree that it needs to be done because it is fundamental. A culture and leadership programme has been put in place, and we have set up national guardians, the idea being that everyone in every trust has the freedom to speak up. There are 800 of them as of today. I take this issue seriously and I commit—if I am here—to come back within four to six months to report to the House on the progress made, as requested.

[Lord Berkeley of Knighton (CB)]

My Lords, all too often we hear sentiments of regret and apology—“we have learnt lessons”; “it must not happen again”—and of course, in a sense, what else can you say? My noble friend’s suggestion of someone with specialist knowledge overseeing this is very helpful, but does the Minister agree that this is another area where we have to encourage people to whistle-blow? It is not a term I like much, because it suggests something which is not pleasant, but very often there are people who are alarmed and think something is wrong, but who are too frightened to speak out. If we could foster a culture where that fear is diminished and people feel able to speak out, and that they should, we might get much earlier warning.

[Lord Markham (Con)]

I agree, and if I may I would like to quote Dr Bill Kirkup in the report:

“Clinicians should not have to live in fear”


where “honest clinical errors” are made. That is exactly the point: we need to introduce a culture whereby people feel able to do that. He goes on to blame systemic failures in leadership, a point that the noble Baroness, Lady Brinton, made, and which is very pertinent here. We are talking about honest mistakes. Everyone wants to do a good job and tries do a good job; it is where they feel that they cannot bring up and honestly discuss those issues that we have a systemic problem, so I agree that it begins and ends with the leadership.

[Lord Inglewood (Non-Afl)]

My Lords, I know nothing about health policy, Kent or the hospitals in Kent, but our grandson was born in one of the hospitals of the east Kent trust earlier in the summer. We have heard about some of the horrifying things that have happened. There is no excuse for that, but in all hospitals and such establishments there are people who, despite the problems, are doing the real job to the best of their abilities. I should simply like to put on record our gratitude to the staff involved in the birth of our grandson.

[Lord Markham (Con)]

I thank the noble Lord. As he rightly points out, the vast majority of workers are very diligent and good at what they do, and that should rightly be recognised. At the same time, I do not think any of us here wants to sweep under the carpet the problems that clearly exist. We need to be sure that, among the fantastic work, we are ever vigilant to root out the bad.

[Baroness Bennett of Manor Castle (GP)]

My Lords, a Department of Health statement on the appointment of the first ever patient safety commissioner—on which, as your Lordships’ House well knows, the noble Baroness, Lady Cumberlege, was a driving force—noted that the NHS Patient Safety Strategy was published in 2019

“to create a safety learning culture across the NHS”.

The statement also noted that it had introduced a statutory duty of candour, which requires trusts to inform patients if their safety has been compromised. I think everyone in your Lordships’ House is well aware that our NHS staff are exhausted, overstretched and overworked. When I read that statement, I could not help thinking about how there are different reports, strategies and approaches coming from all kinds of directions. Can the Minister assure me that staff are being given clear leadership from the very top and a clear framework in which to work, rather than a continual barrage of directions without the resources to deliver them?

[Lord Markham (Con)]

I believe that staff are now being given that framework. Historically, as the report shows, they have not always been given that. Clearly, if this report is really going to lead to meaningful change, we have to make sure that the framework is adhered to going forward. That is what I believe the maternity support programme is all about.