This blog post was published by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.
On 1 November 2022, Dr Bill Kirkup, lead investigator for the investigation into maternity and neonatal services at East Kent Hospitals University NHS Foundation Trust, presented the investigation report: Reading the signals.
Setting the scene
He started by setting the scene. He described the language and behaviour that was used between staff at East Kent Hospitals University NHS Foundation Trust (the Trust) – the rudeness and bullying that Trust staff experienced. This produced barriers, difficulty in speaking up and made it hard to work in teams. Staff did not feel supported. There was a degree of tribalism within the organisation between different groups, clinicians and hospitals. People forgot what they were there for – that is care of women and their families. Technical ability is not enough.
He recommended that changes need to be made in undergraduate and postgraduate training to improve attitudes and behaviour. This needs high-level ownership and broad implementation.
Partly due to the issues highlighted above, there was flawed teamworking, with people pulling in different directions. This was a result of silo working and rigid risk classifications. There were examples of missed opportunities to change and improve care if people listened and worked together to find the common ground for optimal care.
Bill Kirkup recommended that the relevant national organisation 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 of doctors to improve support, teamworking and development.
Dr Kirkup then spoke about the organisational behaviour that he uncovered.
He particularly highlighted the push back that occurred to evidence of concern.
Starting in 2009, there was clear evidence of problems within East Kent Hospitals University NHS Foundation Trust (the Trust), but this was ignored within the trust. People thought the evidence was wrong and quoted anything that suggested the Trust was good. Basically, they made sure they were looking good, while doing badly. This was fed up the system within the Trust to the board and the concerns were not shared or believed. This meant that the oversight groups within the region did not have sight of the problems and change was not implemented.
Bill Kirkup recommended that there should be a duty for public bodies not to deny, deflect and conceal information from families and other bodies. NHS England needs to reconsider its approach to poorly performing trusts, with particular reference to leadership.
Monitoring safe performance
He finished by talking about monitoring safe performance, particularly highlighting the fact there was clear evidence that things were going wrong, but the Trust did not find the signals among the noise or misunderstood them when they saw them.
Individuals highlighted concerns, incidents were investigated and external bodies (some invited in) told the Trust where the problems were, but action was not taken. The Trust looked for reassurance, thought incidents were ‘one offs’ or it was X’s fault and we have removed them/sent them for training. There was no team development, no whys asked and no one asked ‘what can we do?’.
Bill Kirkup recommended that the system should introduce valid maternity and neonatal outcome measures capable of differentiating signals among noise to display significant trends and outliers, for mandatory national use.
As a sign of a great presentation, there was a very active discussion.
There was a lot of agreement that what was seen in East Kent is seen elsewhere in the country. The problem of tribalism was prevalent, but it was wider than just between midwives and doctors.
There was also concern around the problems of hospital mergers which led to a cosmetic change, but the hospitals continued to work independently with their own prejudices and a variation of practice.
It was obvious that there had been no ownership and missed opportunities to change within maternity services. There has been a lot of ‘reputation management’ seen, with a lack of acknowledgement of the problems that existed.
The overall problem is one of lack of ownership and understanding who is responsible to lead on and make the changes that are required.
The fundamental conclusion is that the East Kent report has brought validation of what HSIB maternity investigations found and that we were correct to highlight them. This allows us to move forward into the Maternity and Newborn Safety Investigations Special Health Authority (MNSI) knowing we have an important role in the future to help implement change.