Key Findings from Kirkup Report into baby deaths and failings at East Kent Hospital Trust

Dr Bill kirkup led the investigation into maternity services at East Kent Hospitals Trust.

A damning report into maternity failings at East Kent Hospitals University NHS Foundation Trust has been published.

It found a "clear pattern" of "suboptimal" care which led to "significant harm" at the Queen Elizabeth The Queen Mother Hospital (QEQM) in Margate and the William Harvey Hospital (WHH) in Kent between 2009 and 2020.

Here are the key findings from the study, which was chaired by Dr Bill Kirkup:

- "There were "gross failures of teamworking"

The report found that a "culture of tribalism" among different professions, including midwives, obstetricians, and paediatricians "hindered the ability to recognise developing problems" meaning that intervention was delayed.

"The dysfunctional working we have found between and within professional groups has been fundamental to the suboptimal care provided in both hospitals", the report summarises.

- There were "failures in professionalism"

The report found "clear and repeated failures" in professional standards, including staff being "disrespectful to women" and "disparaging about the capabilities of colleagues in front of women and families".

Staff sought to "deflect responsibility" when something went wrong, while patients were even "blamed for their own misfortune".

- Many staff members were found to lack compassion

Authors of the report said they were "shocked" by "many examples of uncompassionate care", including a woman who asked for additional information on her condition during an antenatal check being told to "look on Google".

- Staff failed to listen to patients and each other

There were "repeated" failures to listen, some of which resulted in a different clinical outcome.

A "pattern" of "dismissing what was being said" also "significantly" contributed to the "poor experience of families" investigated.

- Many safety incidents were not dealt with properly

The authors said "the same patterns of dysfunctional teamworking and poor behaviour marred the response by staff after safety incidents" including those which led to "death or serious damage".

"Staff not only failed to show compassion, they also denied responsibility for what happened, or even that anything untoward had occurred" and the investigators found "instances where the mother was blamed for what had happened".

- There were "failures" in the Trust's response, including at Trust board level

The Trust gave the impression of "covering up the scale and systematic nature of problems" by blaming "junior staff" and "locum medical staff" when they occurred, according to the report.

It also tended to replace staff in key managerial roles if they challenged poor behaviour, so that remaining staff were those who "either personified the poor culture or were prepared to live with it rather than question it".

The report calls out the Trust board for endorsing a "succession of action plans" which "masked the true scale and nature of problems" and perpetuated a "cycle" prohibiting improvement.

A high turnover of staff at many levels, including the chief executive, served to "encourage this cycle", the report said.

- Key figures on deaths and mistakes:

The clinical outcome in 97 of 202 cases could have been different if nationally accepted standards were followed. In 69 of the 97 cases, it is predicted the outcome should reasonably have been different - and could have been different in a further 28 cases.

Of the 65 baby deaths examined, 45 babies could have lived or may have lived if they had been offered nationally recognised standards of care.

The outcome would reasonably be expected to have been different in 33 of these 45 cases while in a further 12 cases it might have been different.

In 17 cases of brain damage, 12 cases could have had a different outcome if good care had been given, of which nine should reasonably have been expected to have had a different outcome. In nearly half of all cases examined by the panel, good care could have led to a different outcome for the families.

The investigation further found that when it came to injuries to mothers, and the deaths of mothers, the outcome could have been different in 23 out of 32 cases.

In 15 of these 23 cases, the outcome would reasonably have been expected to be different.