I made a statement on 28th January about concerns regarding maternity services in East Kent Hospitals University NHS Foundation Trust. I explained that I had sought reports from both the Health Service Investigation Branch and the Care Quality Commission and asked them to report back in fourteen days. I have now received these reports and an update from NHS Improvement and NHS England and would like to make a statement.
The most important thing when having a baby is that you expect to receive the safest possible care. When things go wrong that lead to harm, it is devastating for all concerned. Therefore, I would like to express my deepest and heartfelt sympathies for the patients and families of those affected.
The key partners within the health system continue to work with the trust to identify the problems in maternity services and to ensure that swift remedial and appropriate action is taken. We all want and need to know that the care delivered is of the highest standard we would wish for ourselves and for our families.
Diagnosis (HSIB and CQC)
The Healthcare Safety Investigation Branch has conducted a number of maternity investigations at the Trust as part of its national maternity investigation programme. It has started 25 maternity investigations at the Trust since July 2018, of which 16 have been completed. These have identified a number of safety concerns, including the availability of skilled staff, particularly out of hours, access to neonatal resuscitation equipment, the speed with which patient concerns are escalated up to senior clinicians and obstetricians, along with failings in leadership and governance.
As requested, the Care Quality Commission carried out an unannounced inspection of East Kent Hospitals University NHS Foundation Trust’s maternity service between 22 January 2020 and 5 February 2020. The Care Quality Commission inspected the maternity provision at William Harvey Hospital, Ashford and the Queen Elizabeth The Queen Mother Hospital, Margate. These two sites provide the acute inpatient care and the vast majority of the Trust’s maternity service.
The Care Quality Commission has written to the Trust with an overview of its findings and the full inspection report will be published in due course. The CQC received additional information from the Trust on Tuesday, following their request for further assurance on triage and day care and medical staffing. CQC are considering this information and are in regular contact with the trust leadership to gain assurance of the required actions. The Care Quality Commission will continue to engage with the Trust on all these issues and consider whether any further action is necessary. It is important that everyone is aware, the CQC are in regular contact with the Trust and will continue to be so for the foreseeable future.
Robust actions in hand
From the findings provided to me it is clear that the challenges at East Kent point to a range of issues including having the right staff with the right skills in the right place, effective multi-disciplinary working, clear collaborative working between midwives and doctors, good communication and effective leadership support. But it would be wrong to speculate that there is one single cause.
NHS England and Improvement are working very closely with the Trust.
They have taken some immediate actions.
Firstly, the Regional Medical Director and Regional Chief Nurse are providing support to the Trust. The Medical Director will address concerns surrounding appropriate senior medical oversight.
Secondly, the Regional Chief Nurse is providing support to the Director of Nursing and Head of Midwifery to prioritise and focus their local maternity improvement plans to address identified safety concerns. They will also review the effectiveness of clinical governance and executive leadership support, and this will include ensuring the Trust is taking the learning from all historical cases and disseminating that learning throughout the Trust.
England’s excellent chief midwifery officer, Jacqueline Dunkley-Bent, has sent an independent clinical support team into the Trust to provide assurance that all measures possible are being taken. This expert team includes a director of midwifery services from a CQC-rated outstanding Trust, two consultant obstetricians and consultant paediatrician and neonatologist. She has placed the very best at the heart of the Trust, on the wards, at the bedside of patients with fresh eyes to oversee the care which presently delivered.
The independent team is working with Trust staff to deliver immediate improvements to care and to put in place robust and comprehensive processes to support improvement in standards over the long term. This input will also support East Kent to meet the ten essential safety actions set by NHS Resolution’s maternity incentive scheme.
Along with the fourteen day reports, I can offer further reassurance that Jacqueline Dunkley-Bent personally visited the Trust two weeks ago to assess changes being put in place and that improvements are moving at pace.
Jenny Hughes, chief midwife for the south east region - is also working with the Trust directly.
NHS England and NHS Improvement regional and national teams will continue to work with the Trust, with families where appropriate and with the intensive support team.
The Trust’s Board is taking the issues seriously and is working closely with NHS England and Improvement. The Trust has already implemented a number of actions to improve safety. It has created and filled several specialist midwife posts. Safety huddles, where safety issues are regularly and frequently discussed, have been embedded on both sites to anticipate problems before they occur, and multi-disciplinary teams work collaboratively and effectively within these huddles. A protocol to ensure that CTGs - records of contractions and fetal heart rate - are subject to a ‘fresh eyes’ check by another member of staff is working well.
The Trust has also developed its approach to working with families in the sad case of a death, to ensure that it always provides a point of contact and that it includes and involves families in its investigations of these incidents, from the moment a serious incident occurs.
Sympathies and Assurance
A dedicated Quality Surveillance Meeting with the Trust, Care Quality Commission and key health system partners is scheduled for 21 February 2020 to consider the trust’s actions to date and any further interventions required. I have asked for regular frequent updates plus a further update after this meeting.
We never will be complacent, and I can confirm to the House that I have had assurance from the Care Quality Commission that they are content that the trust is taking the issues identified seriously and has a genuine desire to make the necessary improvements. The Care Quality Commission also notes that the Trust has a number of mitigations in place, including accepting NHS Improvement’s offer of maternity safety support, and the Care Quality Commission will be closely monitoring how the trust responds to the issues that it needs to address and I expect to be regularly updated.
It is critical that we continue to strive to make maternity care the safest it can be and to ensure that we build a learning culture in the NHS as set out in the NHS Patient Safety Strategy. This requires leadership at all levels. This is why I have sought and had assurance from each part of the health and care system that they will continue to work with clinical and executive teams at East Kent Hospitals to make improvements to maternity and neonatal services across all sites operated by the Trust.
Once more, I would like to express my deepest sympathies for the patients and families of those affected.
This statement has also been made in the House of Lords: