Monday, April 15, 2024
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East Kent maternity – the canary in the NHS coal mine


THE media’s obsession with the cynical Whitehall farce dominating the political stage has pushed other crucial news items out of sight. The one which should concern us most is the publication by the Government of a report into maternity and neonatal services in East Kent. 

Such reports are generally only skim-read by the media and might generate a few shock headlines only to be largely forgotten other than by the distraught families of the babies involved. Even the report’s author, Dr Bill Kirkup, strikes a sombre note at the start by stating that the traditional approach of such reports, tried by almost every investigation in the last five decades, is to generate a series of recommendations and policy changes. But he concludes that this approach simply ‘does not work in preventing the recurrence of remarkably similar sets of problems in other places’.

For those familiar with such reports this one is depressingly similar; the same issues come up again and again. A litany of stillbirths, neonatal deaths and brain-damaged babies with the usual associated poor clinical practice of botched assessments, missing records and inadequate foetal monitoring.

Dysfunctional staff relationships with bullying and harassment being regularly reported, but with no effective resolution. Consultants with ‘challenging behaviours’, that is complete bastards, were allowed to continue unchecked. They were frequently missing from daily ward rounds, and some were reluctant to attend emergencies during the night despite being on call. Kirkup also found poor relationships between the midwives and with the other doctors.   

The effect of this on staff morale was appalling and associated with rapid staff turnover. Relatively inexperienced junior doctors were afraid of escalating concerns for fear of an ‘earful’ and in consequence developing clinical issues were not recognised, ignored or dealt with incorrectly.

Equally bad was the attitude of (some) staff to the parents with shocking lack of compassion and failure to listen. I was quite distressed reading accounts of some of the behaviour meted out to the mothers. When things went wrong the Trust covered up and obfuscated. There was an attitude of blaming the patient which sadly, in my experience, is all too common throughout the NHS where minimising reputational damage is deemed more important than addressing the issues.

Another regular failure was the inability to report, discuss, reflect on and learn from serious incidents which should be the foundation blocks of good clinical governance. No clinical service is perfect and things can and will go wrong from time to time. But clinical staff who cannot recognise, acknowledge and learn from these incidents are foolish, incompetent and ultimately dangerous.

Since 2010 a significant number of concerns had been raised around complications in the East Kent maternity services which generated a whole series of external reviews from various regulators such as the Care Quality Commission and the Royal College of Midwives. However their findings were received by the trust with great hostility, and Kirkup’s review found no evidence that any recommendations for change had been implemented, which he detailed as a list of ‘missed opportunities’.

One of the saddest statements in his report is this: ‘Even had none of the previous failings been known – and they were – baby H’s death should surely have been a catalyst for immediate change. In fact, it required public remonstration by a coroner over two years later, precipitated by the persistence, diligence, and courage of baby H’s family, to reveal an organisation that did not accept its own failings, considered itself above scrutiny or accountability, and consistently rejected the opportunity to learn when things went wrong’. (Para. 1,113) This conclusion is devastating. 

Kirkup is equally frank in identifying where responsibility for the service ultimately lies, namely the CEO and the Trust board. But as was the case in the Ockenden report into maternity services in Shrewsbury and Telford, there was a revolving door as far as the senior executives and Trust board members were concerned. This always denotes a hospital Trust in trouble since there is no clear established oversight over a significant period of time.

So although this report has been largely ignored by the media why do I believe it is so important? The fact is that maternity services are the ‘canary in the coal mine’ within the NHS. In normal clinical services where very frail, sick or elderly patients are being managed in large numbers negative outcomes, including death, are regular occurrences. It therefore becomes difficult to identify patterns of poor management or outcomes unless they are very extreme, as for example in the North Staffordshire Trust.

But pregnancy and childbirth are natural, healthy processes under normal circumstances and although things can and will go wrong despite the best care, these should be the exception. When there is a significant increase in adverse events including stillbirth, neonatal deaths and brain-damaged babies, alarm bells should be ringing from ward to board. Maternity is a microcosm of the whole hospital Trust. If significant issues are not being identified there, then this likely reflects the culture of the Trust as a whole.

We are regularly being told these days that the NHS is broken and this largely relates to intense pressure on A&E departments, ambulance services and waits for non-urgent treatments. However I am fearful that beneath these headliners there are far more significant matters which are being hidden by the noise of the other issues, but which the ‘canary in the coal mine’ is now revealing.

My own experience of clinical governance, the process by which lessons are learned and practice improved, is that in many Trusts it is largely patchy at best or non-existent other than in name only. In this report Kirkup avoids giving specific recommendations to improve clinical practice on the grounds that the other reviews had already given plenty, but with no evidence that they had been implemented. Instead he gives four general recommendations for the NHS as a whole which may be seen in the last section of his report. His sense of weariness with the whole, often futile, process is evident.

Over a decade ago some friends had their first child, who tragically was found to have a severe, birth-related hypoxic brain injury. The child will require intensive support for the rest of life. The hospital would be required to hold a statutory Serious Incident Review, but the parents, being kindly souls and not wanting to point the finger of blame at those who, they were sure, were doing their best, did not press the matter. A doctor told them that there had been no single big issue to cause the problem, but rather a number of small issues which compounded. So that’s all right then! Small issues but a severely disabled child.

The current Whitehall farce will soon come to an end, and no doubt someone will lose their trousers in the process. But will anyone really get to grips with the real chaos that is the NHS?

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Dr Tom Goodfellow
Dr Tom Goodfellow
Tom Goodfellow is a retired NHS consultant radiologist who had a specialist interest in paediatrics and cancer diagnosis.

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