RCPCH response to the Kirkup review of East Kent Hospitals

On 19 October 2022 Dr Bill Kirkup CBE published the findings of the Independent Investigation into East Kent Maternity Services in his report Reading the signals: Maternity and neonatal services in East Kent.
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The independent investigation was launched by then Minister for Patient Safety, Nadine Dorries MP, following concerns about the death of a number of babies in recent years. 

Dr Kirkup has previously led a number of independent investigations, including into Morecambe Bay maternity services. The Terms of Reference for the investigation were published in Parliament on 11 March 2021 and can be found here.

The report identifies four areas for action: 

  • Identifying poorly performing units
  • Giving care with compassion and kindness
  • Teamworking with a common purpose
  • Responding to challenge with honesty 

The RCPCH has been asked to consider two key recommendations:

  • Relevant bodies, including the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives and the Royal College of Paediatrics and Child Health, be charged with reporting on how teamworking in maternity and neonatal care can be improved, with particular reference to establishing common purpose, objectives and training from the outset. 
  • Relevant bodies, including Health Education England, Royal Colleges and employers, be commissioned to report on the employment and training of junior doctors to improve support, teamworking and development.

In response to the publication Dr Camilla Kingdon, President at the Royal College of Paediatrics and Child Health said:

As a paediatrician, my whole heart goes out to all the families who have lost their loved ones, just at the start of their lives. We truly hope that the commitment to action this report outlines provides some comfort. 
We are grateful to Dr Kirkup and his team for bringing together this report, and ensuring that the families of those impacted were involved in the process. 

The report outlines a series of terrible consequences, with babies dying in situations that no family should ever have to face. It would be bad enough if this was the first report of this kind.  However, sadly this is not the first report, Dr Kirkup has previously led the review into Morecambe Baywhile in Wales, an Independent Maternity Services Oversight Panel was established in 2019 following tragic events at the former Cwm Taf University Health Board and continues to report on the implementation of changes, and Donna Ockenden set out her independent review into Shrewsbury and Telford’s maternity services. We cannot continue describing these tragedies.  As a country we need to swiftly learn these lessons. 

It is shocking to read of the break down in team working across maternity and neonatal care at the Trust. We know good quality and safe patient care is provided when colleagues across the multi-disciplinary team work openly, honestly, supportively and with a no-blame culture. As a Royal College we stand ready to work with others to discuss how we can help ensure teamworking in maternity and neonatal care can be improved across the system, and as the report states “with particular reference to establishing common purpose, objectives and training from the outset”.

We will also work with relevant bodies on the employment and training of junior
doctors to improve support, teamworking and development and the reporting of this. 

Following the Ockenden report, the health secretary at the time committed to taking quick and robust action. This is currently stalled. As an immediate step, we call on the current health secretary to ensure this moves forward as quickly as possible and no family has to experience what the families in East Kent and Shrewsbury and Telford had to go through. 

As a College we will now consider all the recommendations in detail. 
 


You can also read our response to the Ockenden review published 30 March 2022.