Dr Kirkup’s pessimism has led him to propose a new approach to major service failure in maternity services. No changes of policy directed at specific areas of practice or management are made - a direct contrast to the approach of previous maternity inquiries such as University Hospitals of Morecambe Bay NHS Foundation Trust and more recently The Shrewsbury and Telford Hospital NHS Trust. Instead, the report identifies four key areas for action involving a broader-based approach, together with a specific recommendation directed at East Kent Hospitals University NHS Foundation Trust.

Key findings

The investigation involved maternity services at two Trust sites: the Queen Elizabeth, The Queen Mother Hospital, Margate and the William Harvey Hospital, Ashford, between 2009 and 2020. A ‘clear pattern’ was found: suboptimal clinical care leading to significant harm; failure to listen to families; and acting in ways which made families’ experiences ‘unacceptably and distressingly poor’.

At any time between 2009 and 2020 problems with the service ‘could and should’ have been acknowledged and tackled effectively. Eight ‘clear separate opportunities’ were missed between 2010 and 2018. Had care been given to the nationally recognised standards, the outcome could have been different in 48% of cases assessed and in 69% of cases involving the sad death of a baby. In c.75% of all cases considered there was some degree of suboptimal care. There has been no discernible improvement in outcomes or suboptimal care during the period.

Four areas for action

Monitoring safe performance – finding signals among noise.

In essence this, involves better identification of poorly performing units.

  • It will involve the generation of measures that are meaningful, risk adjustable, available and timely.
  • The measures must be analysed and presented in a way that shows both the effects of random variation (‘the noise’) inherent in all measures, and those occurrences and trends that are not attributable to random variation (‘signals’ or outlying events).


The prompt establishment of a Task Force with appropriate membership to drive the introduction of valid maternity and neonatal outcome measures capable of differentiating signals among noise to display significant trends and outliers for mandatory national use.

Standards of clinical behaviour – technical care is not enough

More needs to be done to ensure that care is given with compassion and kindness. For example:

  • Professional behaviour and compassionate care must be embedded as part of continuous professional development at all levels.
  • Listening to patients must be re-established as a vital part of clinical practice.


  • 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.
  • 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.
Flawed team working – pulling in different directions

There needs to be a stronger basis for team working in maternity and neonatal services. This requires:

  • An integrated service and workforce with common goals and a shared understanding of the individual and unique contribution of each team member.
  • Teams who work together to train together.


  • 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 team working 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, employers, be commissioned to report on the employment and training of junior doctors to improve support, team working and development.
Organisational behaviour – looking good while doing badly

Challenges should be responded to with honesty, rather than thinking first of managing the organisation’s reputation. Previous attempts to encourage organisations to change behaviour have not worked.

  • Failure to respond appropriately not only prevents learning and improvement, but is no way to treat families.
  • The need for openness, honesty, disclosure and learning must outweigh any perceived benefit of denial, deflection and concealment.


  • The government to reconsider bringing forward a bill placing a duty on public bodies not to deny, deflect and conceal information from families and other bodies.
  • Trusts be required to review their approach to reputation management and to ensuring there is proper representation of maternity care on their boards.
  • NHSE reconsider its approach to poorly performing trusts, with particular regard to leadership.


The action points cover a number of themes which have featured in previous investigations and inquiries into NHS service failures. Healthcare organisations should keep under close review:

  • the efficacy of their training programmes
  • policies and procedures for ensuring the duty of candour is understood fully and complied with
  • the appropriateness of serious incident investigations - that they are both timely and thorough and that action plans are monitored to ensure that they deliver on the prevention of future harm.

Dr Kirkup’s approach to learning from events at East Kent is a clear departure from other reports into maternity service failure. His broad approach involves many stakeholders. There will be logistical challenges to drive the proposed reforms forward at a time when health sector organisations are facing numerous challenges including transition to the Patient Safety Incident Response Framework. Time will tell whether this report is a watershed moment which prevents NHS maternity service failure in the future.

How Capsticks can help 

Capsticks is a national leader in representing both NHS and private healthcare providers as well as medical malpractice insurers. Our dedicated team is renowned for advising on the defence and resolution of clinical negligence claims, inquests, management of complaints and serious incident investigation/ inquiries, and providing an innovative outsourcing service for claims and inquests handling.

We are holding a Clinical Risk Forum on 16 November 2022 ‘Maternity care in focus’ If you would like to join us please register here.

If you have any queries on the topics discussed in this insight, or the impact on your organisation, please contact Philip Hatherall, Catherine Bennett or Charlotte Rathbone.