It’s time to break to cycle – “it will not happen again”

The long-awaited Report, led by Dr Bill Kirkup, into the Maternity and Neonatal Services at East Kent Hospitals University Foundation Trust has now been made public.

Quite possibly, the most hard-hitting statement made is that ‘in nearly half of the cases assessed by the Panel, the outcome could have been different had care been given at the standards expected nationally.’

The statistics are alarming. In ’97 of the 202 cases assessed or in 45 of the 65 baby deaths,’ the result could have been different. In real terms, this means many families may have avoided the devastating loss of their child.

It is documented that ‘the Trust must accept the reality of these findings and acknowledge the unnecessary harm caused, and embark on a restorative process’. However, from reading the revelations and experiences of those involved in the investigation, it is clear that these families carry more than the weight of bereavement; they experience overwhelming guilt, mistrust, self-blame, and fear of having another child, and some have suffered relationship breakdowns. The acknowledgement of this wider impact is only the start.

Among the pages of damning evidence, it is clear that the Report has been handled differently to previous investigations making specific policy changes and recommendations. Instead, the Report identified four key areas for action within the services, which have been heavily focussed on the experience of families, with the aim of being a ‘catalyst for tackling these embedded, deep-rooted problems.’

1. Monitoring Safe Performance

It has been recognised that the Trust has inappropriately relied on statistics for reassurance. The Trust was falsely comforted by the fact that most deliveries result in no harm to mother or baby, and refused to acknowledge or investigate their failings. The Trust failed to recognise the scale and nature of its problems. The Report recommended that a task force is implemented to measure maternity and neonatal outcomes for national review.

2. Standards of clinical behaviour

Notable failures were documented regarding lack of compassion and kindness and simply not listening to patients. Listening to a patient can be the difference between a good and disastrous outcome. Time and time again, mothers have reported being ignored;

• “I was saying ‘look I’m really swollen’, but they didn’t listen, they didn’t take on board the things I was pointing out’.
• “I just wish so hard that when I went and said she was not moving the way she should be, that if they’d listened to me seriously…

Families reported that decisions or information given wasn’t explained, insensitive comments were made, and situations led to a loss of dignity.

The Panel found that ‘these experiences have been so damaging [to the families] as to have had a profound and lasting effect on their health and wellbeing.’

The recommendation has been made for an agreed standard of professional behaviour.

3. Flawed teamworking

Clinical care relies on different professionals coordinating and bringing their skills and experience together, and this is imperative in maternity and neonatal services.

The Report highlighted the appallingly dysfunctional teamwork, which resulted in a complete lack of effective communication or continuity of care. The unprofessional manner of midwives, consultant obstetricians and management staff directly resulted in many woman and families suffering their darkest of days. It is understood that ‘midwives who were not part of the favoured in-group were assigned to high-risk mothers and challenged to achieve delivery with no intervention.’ There was a level of bullying to such an extent that the maternity services were not safe.

The Report has recommended the relevant bodies establish how care can be improved and recognise a common purpose. This is to be implemented through training and in-house support.

4. Organisational behaviour

It was clear that the Trust was concerned about managing its reputation and a refusal of scrutiny led to misreporting.

Failures identified in this Report were systemic and at all levels, which showed the attitude to behaviour and teamwork and a persistent failure to look and learn. The issues were known to ‘senior management, who were in a position to act but instead ignored the warning signs and challenges attempted to point out problems.’

This deep-rooted and multilevel involvement requires the Government to act and ‘reconsider bringing forward a bill placing a duty on public bodies to not deny, deflect or conceal information.’

The impact on the families

However, none of these recommendations release the families of the trauma which they are undoubtedly reliving today, recalling the moment they were told:

• “Some parents just aren’t supposed to have children.” or hearing: “sorry for your loss, but our baby was dead and there were other babies who were still living that she needed to attend to.”

Or women being placed with new mothers and their newborns following the loss of their own:

• “It is soul destroying to hear the cries of healthy babies being born knowing that your baby will be born silent.”
• “Spending about 24 hours on the labour ward listening to other babies crying was hell on earth.”
• “It didn’t make it easy for us; having to come out and see lots of happiness and we were going through the worst point ever.”

Families finding out that their situation could have been very different must cause overwhelming heartache. Learning that their baby could have survived or not suffered life-changing injuries if communication had been better and a consultant had been prepared to listen, or a junior felt unable to ask for help when a difficult clinical situation arose; or a midwife was not ‘challenged’ to achieve a high-risk delivery on her own as if the lives of mothers and babies were a game,.

As Dr Bill Kirkup remarked in his open letter, ‘thanks are due to the families… We owe it to them to listen and learn, not only for East Kent but for NHS services elsewhere.’

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