AIMS statement on the Kirkup Report

AIMS Campaigns team, November 2022

It is devastating to read this report, which describes and evidences failings across all domains of the maternity services at East Kent Hospitals University NHS Foundation Trust. The statistics showing how many of the tragic outcomes could have been different with better care make for hard enough reading (P31, table 4, 2.14 – 2.17), but the testimony of women and families throughout the Report is harrowing. Our first thoughts are with the families who now live with the sorrow and long-term consequences of the poor-quality care they received. We recognise that these events affect people for the rest of their lives and hope that the findings of the East Kent Report go some way to provide recognition of their experiences not just for the families who took part, but also for other families whose lives were affected by these failings, but did not have their stories heard by the reporting Team. We are grateful that Dr. Kirkup and his team took a ‘families first’, trauma-informed approach, and hope that these voices will drive meaningful change.

We are also mindful of the impact of these failings on midwives, doctors and integrated care teams throughout East Kent and beyond. The effects of bullying, and working in fragmented and dysfunctional teams, have an impact on the well-being of individual health care professionals, as well as the overall robustness of the service. Understanding the relationship between Trusts, their staff and service users is particularly pertinent now, as maternity services are compromised across the UK by attrition, staff sickness and vacancies.

The East Kent Report does not stint in reporting the length and breadth of failings at East Kent, recognising that these failings went on for many years and touched the lives of many families. The Report identifies that problems lay within every level of the services, from the one to one provision of care to women and their families, to the poor performance of the Trusts executive board, and the failure of regulatory bodies to follow-up and ensure that learnings and initiatives were effecting change in the birth room (1.11). The report identifies eight occasions when opportunities for improvement were missed (1.71 – 1.118) and that the origins of the harms identified lay in structural failings in team-working, professionalism, compassion and listening (1.19).

AIMS suggests that each of these findings is symptomatic of two issues which are endemic in UK maternity care. Firstly, that women are not adequately listened to or heard (3.19 and 4.44) , which contributes to the second theme, which is that maternity services are not structured around the needs of women as they move through pregnancy, birth and the postnatal period, but revolve around the administration of the Institution (4.217). This results in a significant disconnect between the people using the service, the people staffing the service and the people running the service (4.16 and 4.222).

‘It is too late to pretend that this is just another one-off, isolated failure, a freak event that “will never happen again”. Since the report of the Morecambe Bay Investigation in 2015, maternity services have been the subject of more significant policy initiatives than any other service. Yet, since then, there have been major service failures in Shrewsbury and Telford, in East Kent, and (it seems) in Nottingham. If we do not begin to tackle this differently, there will be more.’

Dr. Bill Kirkup. P. v.

‘Why are we still seeing the same themes coming up, not just in one Trust but across the country?’ (4.389)

‘That doesn’t mean every hospital is bad, but … I think every hospital has got problems and I think we should be looking at that in a global way …’ (4.390)

In light of this call to think differently about how to develop and improve maternity care in the UK and to recognise the deeply embedded issues across the service, we at AIMS have two specific questions for the bodies identified in the East Kent Report, the General Medical Council (GMC), the Nursing and Midwifery Council (NMC), the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal College of Midwives (RCM), NHS England (NHSE), the Care Quality Commission (CQC), the Healthcare Safety Investigation Branch (HSIB) and Clinical Commissioning Groups (CCGs) ;

Firstly, how will the ‘...very difficult and uncomfortable issues…’ (p. vi) identified in this Report be meaningfully addressed and acted upon by the GMC, the NMC, RCOG, the RCM, NHSE, the CQC, HSIB and CCGs? What immediate and practical actions will these professional and regulatory bodies take to address the attitudes and behaviours identified in successive reports? How will these bodies change the way they work with Trusts and with individual midwives and obstetricians to ensure that their interventions actually result in improved services for women and families, rather than failing to promote change, as was the case in East Kent. (1.51). We at AIMS know too well from callers to our Helpline that the failings evidenced in this Report are not unique to East Kent, nor to the time period this Report covers, but occur in Trusts across the UK and have done for many years.

Secondly, we ask, What are individual maternity service users to do when they experience the poor quality care that is outlined in the East Kent Report? Behind this report are real women and real families, many of whom, in Nottingham and elsewhere, are at this moment worried about their safety, anxious that their concerns and needs are not being heard or responded to. What will the GMC, the NMC, RCOG, the RCM, NHS, the CQC, HSIB and CCGs do to ensure that women and their families have access to effective mechanisms to escalate their concerns and have these heard - both in the moment and after the event? Who will be responsible for stepping in to prevent harm when someone raises a concern about the care being given?

More broadly, we reflect on the research and user experience we have collated, reported on and responded to since our inception in 1960. If the intention of the forthcoming NHS England Single Delivery Plan is to synthesise the findings from Better Births, the Morecambe Bay Report, the Ockenden Report and the Maternity Transformation Programme, and to provide ‘...personalised, safe and equitable…’ care for all, it is time to heed these recommendations, and recognise that the same thread runs through them all. This effort will only be worthwhile if all concerned - finally - act on the findings from these reports, listen to women, acknowledge that there is no one-size-fits-all solution, and develop services that actually serve their diverse needs.

What is needed are joined up initiatives that do not reinvent the wheel, or create additional and unnecessary burdens of administration for already hard pressed care providers, but which do demonstrably meet the needs on the ground. We at AIMS continue to assert that this must mean an active response to the following issues;

• How can we re-establish the focus on Continuity of Carer in the context of this report, which illustrates the potentially devastating effect of failing to listen to women? We appreciate the current staffing issue facing the NHS, but Continuity of Carer enables exactly the compassionate, relational care that is needed. In the light of this report can we really afford not to implement this relational form of maternity care?

• How can the welcome call to develop “common purpose, objectives and training” for all maternity and neonatal care staff (p 161, 6.24-6.31) ensure that these objectives give maternal experience the same priority as bureaucratic or clinical measurements.? We call for maternity care services to move from objectives that solely list actions and outcomes, to include objectives that measure satisfaction… not just intrapartum, but through the whole perinatal period.

• How can maternity services move on from the polarisation of the debate around so-called ‘normal birth’ (p161, 6.26-6.27)? We are calling for physiology-informed maternity services which act both to maximise the chances of pregnancy, labour, birth and the postnatal period remaining problem-free without any requirement for medical treatment and support the delivery of timely, safe and effective medical treatment when this is beneficial and wanted. (See our position paper aims-position-paper-physiology-informed-maternity-care.pdf)

• We call on the agencies and representative bodies named in the report to recognise that ‘Maternity Transformation’ requires a change in the mind-set of all decision-makers, managers and staff, with genuine buy-in to the fundamental changes required of them. To be effective, there must be support and training for implementing changes including cultural changes, and transparency around how Trusts are implementing recommendations and monitoring of their effectiveness. It is also increasingly urgent to find a solution to the staffing crisis.

AIMS will continue to campaign for the improvement of maternity services for all who use them. We do this because women continue to shoulder the burden of the consequences of poor quality maternity care and the ordeal of reporting it and campaigning for their concerns to be heard and acted on - largely on an unpaid and voluntary basis. Now it is time for those who are paid to be responsible for these women to act and to deliver.