Reading the signals: maternity and neonatal services in East Kent

Dr Bill Kirkup · work from 2020 · published 2022

What this was

Independent investigation into maternity and neonatal care in East Kent. It found repeated failures over more than a decade. Kirkup deliberately did not add a long list of new recommendations. He set out four areas for action and argued that the problem was implementation of what was already known.

Why it sits in the hub

This is the hub's central argument, made by the investigator himself: another action plan is not a safety strategy. The four areas — outcomes, behaviour, teamwork, and how organisations behave — are the themes that keep recurring.

Findings

Finding 1
Harm was repeated because signals were visible and not acted on, including what families said.
Data and early warning Listening to patients and families Maternity and neonatal care
Finding 2
Teamwork and standards of behaviour were poor enough to be a clinical risk.
Culture and conduct Training and competence
Finding 3
Previous recommendations had not failed for lack of being written down.
Leadership and boards Learning from harm

Recommendations in this hub

Paraphrase of the public recommendations, not the official text.

1Partly doneNHS England
Monitor outcomes in a way that spots a failing maternity service early.
Data and early warning Maternity and neonatal care
2Not publicly clearRoyal colleges and trusts
Set and enforce standards of clinical behaviour, including how colleagues treat each other.
Culture and conduct Training and competence
3Not implementedGovernment and NHS England
Stop commissioning new recommendation lists as a substitute for implementing the old ones.
Further maternity reviews and a national investigation have been commissioned since.
Learning from harm Regulation and oversight