The Kirkup Inquiry – what lessons can be learned?

Background:

Sadly, this is one of many independent investigations into failures in maternity care in recent years.

This investigation was called as a result of the tireless fight by bereaved grandfather Derek Richford’s.  His Grandson, Harry Richford, died when he was just 7 days old in November 2017.  A catalogue of errors occurred in the treatment of Harry and his mother, Sarah, in the lead up to and following his birth.  An investigation was held by the Trust which failed to identify the failings and the Trust refused to report Harry’s death to the coroner simply saying that the cause of his death was known.

In the midst of his families devastation and grief, Derek refused to accept the false information his family were provided and started to dig deeper into the treatment his daughter in law and grandson had received.  He notified the Coroner and an Inquest was held in 2018 which concluded his death was caused by neglect and highlighted 7 gross failings in care.  Following the Inquest and as a result of reports from the CQC and HSIB, Sir Simon Stevens, CEO of NHS England commissioned the Kirkup Independent Inquiry into the maternity services at East Kent.

The CQC also brought a criminal case against the Trust as a result of the failings in the care of Sarah and Harry.  The Trust were fined over £700,000.

The investigation:

The Kirkup investigation was led by Dr Bill Kirkup (who also led the investigation in to the Morecambe Bay Investigation).  The investigation reviewed the maternity care provided to 202 families at both the queen Mother Hospital in Margate and the William Harvey Hospital in Ashford between 2009-2020.  The report was published on 19 October 2022 and makes for harrowing reading.  The investigation worked together with families and staff at East Kent Hospitals University Foundation Trust.

The report found a clear pattern over the 11 year period that those responsible for providing maternity services too often provided clinical care that was inadequate and led to significant harm.  “They failed to listen to the families involved, and acted in ways which made the experience of families unacceptably and distressingly poor”.  The report states that had appropriate care been provided the outcome could have been different in 97 or 48%, of the 202 cases assessed by the Panel.  The report shows that 45 of the 65 baby deaths, or 69% of babies, would have survived had they received appropriate care.  This is truly heartbreaking.  45 babies died as a result of a failure in care.  In reality this figure is likely to be much higher as the investigation only looked at the care of families who volunteered to be involved.   Even more alarming is that the investigation was not able to detect any improvement in outcomes or inadequate care during this 11 year period.  Lessons were not being learnt and the standard of care had not improved for over a decade.

Themes identified:

The report highlights the harm was caused by failures in team working, professionalism, compassion and listening.

1. There was “gross failures of team working” among and between the midwifery and medical staff.
2. There was a failure in professionalism.  Staff were disrespectful to women and disparaging about colleagues in front of families.  One mother recalls being told “It’s God’s will; God only takes the babies that he wants to take”
3. There was a lack of compassion.  Uncompassionate care can be devastating for the wellbeing and mental death of the recipients.  One mother who pointed out that their analgesia was not effective and that they were in pain was ignored “they didn’t listen…they carried on, obviously, to cut me open.  I could feel it all”
4. There was a failure to listen to families.  In some cases the failure o listen contributed to the outcome.
5. There was an willingness to engage with families when conducting investigations.  Many families reported that responsibility was denied, dismissing that anything had gone wrong or even being blamed for what happened.
6. Lastly, there was a failure to respond to the results of investigations. The Trust found it easier to attribute the causes to individual clinical error.  The problems among the midwifery and obstetric staff were known but not successfully addressed.

Recommendations:

The report made 4 recommendations:

1. Monitoring safety performance.  The setup of a national task force to monitor maternity safety in all Trusts.   This will help to recognize and monitor poorly performing maternity units early on.
2. Standards of Clinical behaviour.  Ensuring that care is provided with compassion and kindness.
3. Flawed Teamworking.  Improved teamworking between midwives and medical staff.
4. Organizational Behaviour.  Responding to challenge/criticism/concerns with honesty

The report also called on East Kent Hospitals University Foundation Trust to accept the reality of the findings in the report and acknowledge in full the harm caused.

Comment:

Unfortunately, the themes identified by Dr Kirkup are not unique to  East Kent and the investigation. Poor teamwork, lack of compassion and a reluctance to listen to and be honest with families are themes which have run throughout all the recent maternity scandals.  I was humbled to listen to Derek Richardson speak about his experience with Harry recently.  He spoke with such raw emotion about the heartache his family have suffered as a result of the treatment provided.  It was clear he was passionate about getting justice for Harry and so many other babies whose deaths were avoidable and to make a difference to maternity safety to protect future families.  However, it shouldn’t be left for grieving families to push for these inquires.  Derek’s last quote was “denial is the thief of learning.”  Never has this been more apparent.  We need to move away from blanket denials and shifting blame and create an open and transparent space where parents concerns are listened to and ensuring that lessons are learnt.

Sadly, this is not the end of the investigations into maternity failings.  Donna Ockenden is currently leading a panel to investigate the care provided at Nottingham University Hospital Trust.  It is hoped that these thorough investigations and recommendations for the future will improve the standard of maternity care provided.  It is vital that action is taken and lessons are learnt nationally to ensure this does not happen again.

I have represented many families who have sadly suffered a stillbirth or neonatal death of their baby as a result of inadequate care.  I have heard the utter devastation and heartache that is caused and my heart and thoughts go out to all the families of East Kent who have been impacted by this report and also all families who have suffered the devastation of the death of their baby.

If you, or a loved one, have suffered as a result of poor care, please get in touch with our Clinical Negligence team for advice.