Dr Bill Kirkup looked visibly distressed as he sat down ahead of the press conference.
His inquiry had looked at maternity care at the Queen Elizabeth The Queen Mother Hospital (QEQM) at Margate and the William Harvey Hospital in Ashford, both in Kent, between 2009 and 2020.
He began the news briefing by saying he wished he did not have to lead another investigation into yet another maternity scandal – he was in charge of the review into Morecambe Bay in 2015.
He said today if the recommendations he made then had been implemented in East Kent then there would not have been so many avoidable baby deaths and harm to mothers.
That is why there is no long list of recommendations following this investigation. He wants to keep it simple, easy to follow, and more importantly easy to implement.
There are four key points that must be actioned immediately to avoid more scandals like this one.
First, a nationwide maternity signalling system to monitor and detect dysfunctional units: too many red flags and warnings were ignored in East Kent.
The next two points involve people – and this is the key to understanding what went wrong in East Kent and elsewhere. It is a recurring theme.
Medical staff at East Kent simply ignored the fears or concerns of patients before, during, and after delivery. It was a ‘we know best’ attitude that traumatised mothers and their families. This response was also evident among staff addressing their colleagues.
There was no teamwork between consultants, doctors, midwives, and nurses. All had different goals and patient safety was not one of them. The evidence points to a toxic atmosphere of bullying and intimidation.
Finally, Dr Kirkup said, it was clear that staff he interviewed had covered up the truth. This culture of denial ran from the ward all the way up to the executive board level.
That is why he wants what he calls a “Hillsborough Style Law”. The inquiry into the football tragedy made it a statutory requirement to tell the truth. This is the fourth modern maternity scandal and more are being investigated.
These are not cases of deliberate clinical negligence or repeated mistakes. Instead, there is something very wrong at the heart of the country’s maternity services; a poisonous culture, where the patient has little or no rights, is easily ignored, and perhaps worst of all made to feel guilty for the outcome.
Read more:
At least 201 babies and nine mothers died as a result of maternity failings at Shrewsbury and Telford NHS Trust
Why do maternity scandals keep happening?
Dr Kirkup said he believed the vast majority of medical staff in maternity work are good people who care deeply about their patients. But sadly their voices are silenced or they are too fearful to step forward when they see wrong.
Unless this is challenged and change is forced, more tragedies like the ones suffered in East Kent will follow.
