East Kent Maternity Services: Independent Investigation

Caroline Johnson Excerpts

Thursday 20th October 2022 Commons Chamber

[The Parliamentary Under-Secretary of State for Health and Social Care (Dr Caroline Johnson)]

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 hon. 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.

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[Dr Johnson]

I thank the hon. Lady for her questions. The report paints a tragic and harrowing picture of poor maternity care at East Kent Hospitals. She talks about accountability. She will be aware that the chief executive and chairman of that trust board have changed, and that those new in their posts are working hard to ensure that things are turned around and improve.

The hon. Lady talked about funding and workforce. I understand why she did that, but if she reads Dr Kirkup’s report, it is clear that they were not causative factors in this case. This was about culture and workplace practice, not money and staffing levels. She also asked how that money has been spent. It has been spent on staffing, workforce and training. She also asked about culture change and how that will be measured. It is being looked at in several ways, particularly in terms of the outcomes, such as healthy babies and the mother’s experience of their care.

[Sir Roger Gale (North Thanet) (Con)]

Mr Speaker, first, thank you so much for facilitating this statement. You know that as not just the constituency Member of Parliament, but a father and a grandfather, this is a matter of profound importance to me personally. Can I welcome the Minister to the Dispatch Box for the first time and thank her for the tone of her remarks?

Nothing is going to bring back the children who were lost in the Margate unit. Nothing is going to erase the pain felt and continuing to be felt by the parents. I would like to commend them for the quiet dignity with which they have fought their cause under horrific circumstances for so long. I would also like, if I may, craving your indulgence, Mr Speaker, to thank Bill Kirkup and his team for the sensitivity with which they have handled this and listened to the harrowing stories from so many people—stories that should never have had to be told.

What we can do is to try to put this right, so that this never ever happens to another family again. It will come at a cost and, with a Treasury Minister on the Front Bench, I have to say that £33 million-worth of investment is now needed immediately in the maternity unit at Margate. What I would like to do at this stage is to ask my hon. Friend to tell me from the Dispatch Box that she is willing to bring her medical expertise, which is considerable, to Margate, and to come herself to see the unit, meet the staff and meet the new chief executive and the new chairman, who are determined to do their utmost to make amends and to do so as swiftly as possible.

[Dr Johnson]

I thank my right hon. Friend for his comments. I note that he has been a doughty campaigner on this issue, and I know how much it matters to him personally, as well as as a Member of Parliament. I would of course be happy to come to Margate to meet the staff he describes.

[Rosie Duffield (Canterbury) (Lab)]

I thank the Minister for her statement, Dr Kirkup and his team, and the families and staff who took part in the inquiry. It is clear that there has been an utterly toxic and dysfunctional culture within maternity services at the East Kent hospitals trust. It is shocking and disturbing, and made so much worse by the revelation that the trust tried to cover up these cases. Mothers were treated appallingly and babies died. I cannot comprehend what they have had to endure, and I am so angry on their behalf. How can the Minister assure my constituents that action leading to immediate change will not involve any of the staff and managers involved directly in these cases? And given that former staff and a governor have said publicly that they cannot recommend the service, how can MPs in East Kent tell our constituents that our maternity services are now safe?

[Dr Johnson]

I know that this is a matter on which the hon. Lady has been campaigning furiously on behalf of her constituents. I share her anger, and her shock when I read the report, at some of the cases and some of the ways in which patients have been spoken to during their time at their hospital. It is truly unforgivable.

On the question of safety, that was my first question when I read the report: are we sure that patients going in today to have their babies are safe to do so? So I met Anne Eden, the regional director of NHSE, yesterday to talk to her about safety, and I have been reassured about both quality and outcomes. On outcomes, I have been reassured that, looking at crude data, which I appreciate has not been published yet, the numbers of stillbirths and neonatal deaths over the last year or so have fallen substantially. On quality, it is doing a review, so each woman is contacted six weeks after her delivery to ask about her experiences, and where experiences have not been as they should be—although they are in almost all cases—that has been further investigated in each case.

[Damian Green (Ashford) (Con)]

This report is a terrible read, particularly, obviously, for bereaved parents, who have gone through untold anguish, including some at the William Harvey Hospital in my constituency. What makes me particularly angry is that this was going on for more than a decade under several different management regimes at the trust. Can the Minister give some reassurance to women in Ashford who are about to have a baby at the William Harvey that they will be treated safely and respectfully, and can she assure the House, looking further afield, that the terrible repeated examples of similar tragedies and scandals around the NHS are now at an end?

[Dr Johnson]

I know that my right hon. Friend shares the House’s desire to ensure that such events do not reoccur, and that his constituents are safe. He asked about failures over time. In fact, there were signs as early as 2010 that problems were being raised with the trust. The failure was not so much to find those problems, but that they were not properly dealt with when they were found. Yesterday, I received assurances from the regional director of NHS England, as I described a few moments ago, and I will meet her regularly to receive updates to ensure that the process is not just put in place but followed through.

[Clive Efford (Eltham) (Lab)]

The stories of the families are harrowing to read. I hear what the Minister says: that staff shortages cannot be used to excuse the poor practice that has taken place. None the less, it is disturbing that NHS England has abandoned its safety targets under the midwifery continuity of care model. When more midwives are leaving the profession than coming into it, as a matter of urgency to avoid such occurrences in other places, what are the Government going to do to turn around that loss of midwives?

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[Dr Johnson]

NHS England has announced that it is investing an additional £127 million into the maternity system in the next year. That money will go towards the maternity workforce and improving neonatal care. In addition, £95 million was invested last year to support the establishment of more than 1,200 more midwifery posts and 100 more consultant obstetric posts. Work is already under way as part of the biggest nursing, midwifery and allied health care professional recruitment drive in decades. That will help us to increase the number of midwives in East Kent but also elsewhere.

[Helen Whately (Faversham and Mid Kent) (Con)]

I thank my hon. Friend for her statement, and particularly for the tone in which she made it. Dr Kirkup’s report is harrowing reading, but nothing compared with the harrowing experiences of the parents whose babies were severely injured at birth, stillborn, or lost in the days after they were born, particularly when so many of those incidents were avoidable. It is a shocking litany of clinical and management mistakes, missed opportunities, failures to take responsibility and an incomprehensible normalisation of baby death, despite all the efforts to improve safety since the Mid Staffs scandal. I ask my hon. Friend to put herself in the shoes of an expectant mum—I know that as a mum she will be able to do that, as well as from her experience as a clinician—and categorically assure me and all the parents to be who are soon to have babies in the East Kent trust, that the maternity units in those hospitals are safe for them to give birth?

While there are worthwhile sections on actions in the report—I commend Dr Kirkup for his report—it does not get to the bottom of the problem, which is truly one of accountability. Can my hon. Friend assure me that never again will a trust find reasons to excuse catastrophic outcomes, that never again can critical reports be dismissed as a “load of rubbish”, and that never again can staff blame patients for a hospital’s failings? How will she assure herself as a Minister—I know this is a difficult role—that every maternity unit in every hospital across the country is safe for mothers to give birth?

[Dr Johnson]

I know my hon. Friend has campaigned hard as both a Minister and a Back-Bench MP for safety in the national health service. On safety at the East Kent trust, we have already talked about the regional team there. There is also a maternity safety support team in the trust working actively on the ground to ensure that lessons are learned and services improved. I have been given some figures that demonstrate that the outcomes are improving. As I said earlier, steps are in place to ensure the quality of service and to feed back the quality of service to ensure that no woman is spoken to in the way described in the report.

From a wider perspective, we are looking at both the workforce as described but also at how we ensure that problems are not just picked up, but developed and followed through. We are also looking at the Kark report that looked at how managers are held responsible. We will talk more about that in due course.

[Rachel Hopkins (Luton South) (Lab)]

Many of my constituents have raised the point that black women in the UK are four times more likely to die in pregnancy and childbirth. Can the Minister explain what action is being taken to end that scandal?

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[Dr Johnson]

From a wider perspective, the Government have a target of reducing stillbirths and neonatal deaths across the country and that, obviously, includes women of colour.

[Tim Loughton (East Worthing and Shoreham) (Con)]

What was particularly shocking about the report, coming hard on the heels of Shrewsbury and Morecambe Bay, was the culture of cover-up that it revealed, the lack of empathy—extraordinarily—among staff and the fact that it took parents and grandparents such as Derek Richford to campaign to get the exposé. Does the Minister agree that, given that liveborn children were described as being stillborn so coroners could not investigate, it underlines yet again the need for my Civil Partnerships, Marriages and Deaths (Registration etc) Act 2019, which was passed by the House three and a half years ago and gives powers to coroners to investigate stillbirths, to come into force at last? Will she go and speak to the Justice Secretary and liaise between the Departments to get that measure enacted straightaway to give some confidence to those parents who have been through these terrible experiences?

[Dr Johnson]

I understand my hon. Friend’s passion in this area. I am happy to meet him to discuss it further.

[Richard Foord (Tiverton and Honiton) (LD)]

We have seen several tragedies in health and social care services across the country. Both the Ockenden review earlier this year and this recent upsetting report by Dr Kirkup highlight serious multiple failings. It should go without saying that health outcomes should never be determined by location. We must tackle the inequalities that exist between rural and urban maternity services to ensure that people living in rural and coastal areas can access the same range of birthing methods and support. Will the Minister support the Maternity Services (Rural Areas) Bill introduced by my hon. Friend the Member for St Albans (Daisy Cooper) to end maternity service inequalities for people living in rural and coastal areas?

[Dr Johnson]

As a rural Member of Parliament, I understand the need for rural services to be just as good as those in more urban areas and to ensure that they are improved where they are not adequate. A medical education reform programme that is co-sponsored by NHS England and Health Education England is expected to direct investment for specialty training more towards area population need—to smaller and rural hospitals. The programme entered its implementation phase in August. Morecambe Bay, East Kent, James Paget and Shrewsbury and Telford are included in our current smaller hospitals list. I am not certain about the hospital in the hon. Member’s constituency, but I can find that information and write to him about it.

[James Morris (Halesowen and Rowley Regis) (Con)]

This is clearly a shocking and disturbing report. I found myself agreeing with the shadow Minister when she said that this represents a serious collective failure across our maternity services, because I know that it is not an isolated incident. Does the Minister agree that there is a role to be played by the Healthcare Safety Investigation Branch, which has set up a stream of work on maternity services? Could she redouble her efforts in conjunction with that body to ensure that we learn the lessons of the cultural failures in this case and that that learning is spread throughout the system? That is the only way we have an opportunity to ensure that these things do not happen again.

[Dr Johnson]

My hon. Friend will be aware that within HSIB the Government are establishing a new special health authority specifically for maternity investigations, with specialist expertise. This independent body will continue the work of HSIB from 2023. In the meantime, maternity investigations will continue without interruption until it is fully operational.

[Jim Shannon (Strangford) (DUP)]

First, I welcome the hon. Lady to her place. We are very pleased to have her expertise and knowledge in that role as Minister. This House will benefit from it. I would also like to express, on behalf of myself and my party, my sincere sympathies to all those who have lost loved ones. I think it is fair to say that we all have those families in our thoughts and prayers. Will the Minister outline what discussions have taken place with devolved health trusts in the devolved nations to share information and ensure UK-wide reform? It is clear that the pressures that led to this terrible scenario in Kent are ready to be replicated through the United Kingdom of Great Britain and Northern Ireland, as midwives battle with understaffed, unsupported and exhausted wards that are on the brink of life-and-death disasters. Through no fault of individuals, midwives will carry that all to their graves. I know the Minister is committed to making it better. How can we do that for all of this great United Kingdom of Great Britain and Northern Ireland?

[Dr Johnson]

It is, of course, important that information is shared across our great country, so that people in all areas of our nation get the best-quality care. Health is a devolved issue, but I will continue to work with Ministers from the devolved nations to ensure we share the lessons and learn from each other.

[Robert Courts (Witney) (Con)]

My constituent Helen Gittos, whose healthy full-term daughter Harriet died in 2014, said:

“Too often during pregnancy, in labour and afterwards, rather than being listened to, we were treated dismissively, contemptuously and without a desire for understanding. It is hard enough to come to terms with the death of a child; it is even harder when you are implicitly blamed for what happened.”

Will the Minister commit to ensuring the implementation of all five recommendations, to beginning the process of doing so by recess, and to making an oral statement to the House detailing what progress has been made, again by recess?

[Dr Johnson]

I know my hon. Friend shares my horror at the report and my horror at the way women and their families were treated at East Kent maternity hospitals. The report was published only yesterday. I will be considering it very, very carefully and will further update the House in due course.