Reading the Signals: Maternity and Neonatal Services in East Kent
South EastIndependent investigation into maternity and neonatal services at East Kent Hospitals University NHS Foundation Trust (QEQM Hospital, Margate and William Harvey Hospital, Ashford), covering care provided 2009–2020. Reviewed over 200 cases involving avoidable harm to mothers and babies. Found a culture of not listening to women, poor teamworking, and a trust focused on "looking good while doing badly". Published October 2022. Government accepted all recommendations July 2023.
Recommendations (8)
1
NHS England
Accepted
Recommendation
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.
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Accepted. NHS England established the Reading the Signals Data Co-ordination Group and the Maternity and Neonatal Outcomes Group to develop clinical outcome measurement tools for mandatory national use.
2i
Those responsible for clinical education
Accepted
Recommendation
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.
Accepted. DHSC coordinating mapping of compassionate care teaching across professions with royal colleges and regulators.
2ii
Royal colleges, professional regulators, employers
Accepted
Recommendation
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.
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Accepted. DHSC leading three-part approach: map oversight responsibilities, share good practice, identify gaps.
3i
RCOG, RCM, Royal College of Paediatrics and Child Health
Accepted
Recommendation
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 …
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Accepted. Royal colleges commissioned to report on teamwork barriers and solutions. PROMPT training incentivised via maternity incentive scheme.
3ii
Health Education England, royal colleges, employers
Accepted
Recommendation
Relevant bodies, including Health Education England, royal colleges and employers, be commissioned to report on the employment and training of junior doctors to improve support, teamworking and development.
Accepted. Reviews examining support structures for junior doctors, SAS doctors, and locums.
4i
HM Government
Accepted
Recommendation
The government reconsiders bringing forward a bill placing a duty on public bodies not to deny, deflect and conceal information from families and other bodies.
Accepted. Government noted existing statutory duty of candour and committed to address alongside the response to Bishop James Jones' 2017 Hillsborough report regarding broader legislative protections for families.
4ii
NHS trusts
Accepted
Recommendation
Trusts be required to review their approach to reputation management and to ensuring there is proper representation of maternity care on their boards.
Accepted. NHS England asked all trusts to review their approaches at board meetings. Executive and non-executive maternity/neonatal board safety champions to be appointed.
4iii
NHS England
Accepted
Recommendation
NHS England reconsiders its approach to poorly performing trusts, with particular reference to leadership.
Accepted. Recovery Support Programme deploys improvement directors to challenged trusts. Broader leadership reviews (Messenger Review, Kark Review) underway.