RCPCH statement on Government response to Bill Kirkup report on East Kent 

On 20 July 2023, the Government published its full response to the independent review – led by former Regional Director of Public Health Dr Bill Kirkup CBE – into neonatal and maternity failings at East Kent Hospitals NHS Trust.
Reports with bar charts and magnifying glass

The review was launched because of concerns about the quality of care being provided by the Trust and outlined in detail the poor maternity care that over 200 families received at the trust between 2009 and 2020, including lessons for the future. 

The Kirkup report identified 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 Government’s response notes that they have undertaken a range of discussions with stakeholders from across the system including some the families who were impacted by the poor care provided at East Kent and includes 4 overarching areas for action. 

The College has been asked to consider the following recommendations specifically, as part of the wider range as a whole: 

  • Recommendation 2i) Those responsible for undergraduate, postgraduate and continuing clinical education be commissioned to report on how compassionate care can best be embedded into practice and sustained through lifelong learning.
  • Recommendation 2ii)  Relevant bodies, including royal colleges, professional regulators and employers, be commissioned to report on how the oversight and direction of clinicians can be improved, with nationally agreed standards of professional behaviour and appropriate sanctions for non-compliance. 
  • Recommendation 3i) Relevant bodies, including RCOG, RCM 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.

The Minister for Women’s Health, Maria Caulfield MP, has announced she will now chair a new group overseeing maternity services nationwide.

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

Dr Kirkup’s review published earlier this year outlined a series of tragedies, with babies dying in situations that no family should ever have to face. As a paediatrician my whole heart goes out to all the families who have lost their babies in unimaginable circumstances.

Sadly this report is not the only one of its kind - with similar recent reviews at Morecambe Bay, Cwm Taf University Health Board and Shrewsbury and Telford’s maternity services in recent times.

We cannot continue describing these tragedies.  As a country we need to swiftly learn the key lessons and now commit to ensuring that no more newborns die needlessly due to inadequate and uncompassionate care.

It is extremely welcome therefore that the Minister Maria Caulfield has announced she will now personally chair a new group overseeing maternity services nationwide – but we need to see real action and reform from this, and promptly. 

We note in the government’s response there are a range of recommendations for Royal Colleges including ourselves. 
As an organisation we stand ready to work with colleagues across the system to ensure that women, babies and families receive the high-quality care that they deserve. However, the issues described in these reports run deep, and there is no silver bullet. Real and necessary change requires prolonged action including: 

  • increasing the workforce numbers
  • improving the culture within these services 
  • defining measurements for success

Our maternity and neonatal services teams have normalised working with partially filled rotas and a heavy reliance on locum and agency staff. We need numbers that ensure stability and sustainability for the future. The workforce plan published earlier this month recognises the need for more midwives, which is extremely positive – but we also need this to be backed up with all groups of staff working across neonatal and child health services.

We note the key point that the working culture within these services must be improved. We are clear that good quality and safe patient care is provided when colleagues across the multi-disciplinary team have manageable workloads and operate in an environment that is psychologically safe and supportive. 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. We also note that much of this can be enhanced with more staff, a better working environment, and adequate funding for services – this needs support from national Government. A culture of trust is  essential, where every member of the team knows they can voice concerns or speak up about areas for improvement. 

Finally, we want to challenge the DHSC, the Minister, and the new Maternity and Neonatal Care National Oversight Group to bring together an action plan which includes how these important recommendations – and others from across the many reviews– are mapped across the whole system and can be measured for success. It is crucial to have appropriate measurements and audits in place otherwise once again these recommendations will fall by the way-side. 
Children, young people, families, patients and the public deserve to have the best NHS care possible. We must all work together to fix maternity care and regain the trust of patients. 

We will now consider all the recommendations in detail with our committees.