Policy paper

Government response to ‘Reading the signals: maternity and neonatal services in East Kent - the report of the independent investigation’

Updated 3 August 2023

Applies to England

Ministerial foreword

All women expect that they and their baby will be cared for safely and, where tragedies happen, that they will be well supported and treated with compassion. This was not the case at East Kent Hospitals University NHS Foundation Trust, and many women, their babies and families were failed in their time of need. Dr Bill Kirkup CBE was commissioned to undertake an independent investigation into the trust’s maternity and neonatal services to understand what happened and why, and, crucially, to identify lessons to prevent it happening again.

I would like to thank the families who have engaged with the investigation. Your willingness to share your experiences, even though those experiences are harrowing for many of you, will support the learning and improvement that can be brought about through these recommendations. I am deeply sorry for the pain you have experienced, and I hope the action being taken because of your participation with the investigations provides some comfort for you in this process.

I would also like to thank Dr Bill Kirkup and his whole team for their committed and compassionate approach throughout the investigation. Your insightful and considered report will enable the healthcare system to reflect and improve on the provision of care and you have provided an important platform to give a voice to so many families.

I take this investigation and all elements of maternity safety incredibly seriously. I understand the immeasurable impact that poor care and adverse outcomes can have on a family, and I remain committed to supporting trusts to deliver safe, compassionate care.

While maternity services must always seek to learn and improve, I would like to recognise the dedication and commitment of the vast majority of the maternity workforce. I know that everyone who joins the healthcare profession sets out to deliver safe and compassionate care, and I would like to acknowledge the effort and ability of so many maternity professionals who work tirelessly for the women and babies they serve. This should be the case for all women and babies.

It is important to acknowledge that we know that care is not always delivered to our high standards. Inquiries into care at Morecambe Bay and Shrewsbury and Telford (see the final Ockenden report) have highlighted terrible examples of unacceptable levels of care.

There has been a significant and sustained effort to improve maternity safety and deliver quality and personalised care across England. NHS England’s Maternity Transformation Programme was established in 2016 to implement a vision for safer and more personalised care across England. The programme was initially guided by Better births, published in 2016, which set out a 5 year forward view for improving outcomes of maternity services.

The NHS Long Term Plan, published in 2019, set out to make the NHS one of the best places in the world to give birth by offering mothers and babies better support and safer care. Most recently, this has been set out in NHS England’s 3 year delivery plan for maternity and neonatal services, which looks to guide the service towards being safer, more personalised, and more equitable for women, babies and families.

It is clear that a vision for safe and personalised care has remained at the forefront of maternity services. We have been deeply saddened by the findings about the care in East Kent. We believe that the work that has been done to improve maternity care provides a foundation for us to build on and improve.

This response will set out the next steps on the important themes and aims within the recommendations that are another key component towards achieving safe and personalised care for everyone.

Maria Caulfield MP
Minister for Mental Health and the Women’s Health Strategy

Introduction

In February 2020, NHS England commissioned Dr Bill Kirkup CBE to undertake an independent review into maternity and neonatal services at East Kent Hospitals University NHS Foundation Trust, referred to in this document as ‘the trust’, following concerns about the quality and outcomes of care.

Dr Kirkup’s Maternity and neonatal services in East Kent: ‘Reading the signals’ report was published in October 2022. This will be referred to as ‘the report’. The report detailed the poor maternity care that over 200 families received at the trust between 2009 and 2020. The report concluded that the trust failed to provide safe care and treatment which resulted in avoidable harm for mothers and babies, causing tragedy and distress that no family should have to experience.

The report demonstrated that the NHS needs to be better at identifying poorly performing units, at giving care with compassion and kindness, at teamworking with a common purpose and at responding to challenge with honesty. The government takes all of the findings and areas of concerns extremely seriously and is committed to continuing its work to ensure that all trusts provide safe and compassionate care at the standard that is expected.

Within his ‘Reading the signals’ report, Dr Kirkup made 5 recommendations for the healthcare system. In March 2023, the government provided an interim response to the report via a written ministerial statement. This fuller response details how we are implementing the recommendations.

To make sure that the recommendations are delivered in a way that results in meaningful change, since the report was published the Department of Health and Social Care (DHSC) and NHS England (NHSE) have together conducted an extensive series of discussions with a wide range of stakeholders across the healthcare system and voluntary sector, ranging from patient groups to regulators including the:

• Care Quality Commission (CQC)
• General Medical Council (GMC)
• Nursing and Midwifery Council (NMC)
• royal colleges
• Healthcare Safety Investigations Branch (HSIB) maternity investigations programme
• NHS Employers
• NHS Providers
• National Guardian’s Office
• British Medical Association (BMA)
• Health and Wellbeing Alliance (HW Alliance)

Professional bodies, regulators and organisations have highlighted the important work already in train to support healthcare professionals to deliver safe and quality care, but also have remained open and committed to learning and improvement across the system. We will continue to build on their expertise and experience throughout the implementation process.

We also heard directly from some of the families affected by the poor care received in East Kent about their experiences and the changes they think are needed to improve services, at a meeting with the Minister for Mental Health and Women’s Health Strategy, Maria Caulfield MP. What they told us has informed this response and will continue to inform the implementation of Dr Kirkup’s recommendations.

One important part of the learning and action taken from the recent maternity investigations is the 3 year delivery plan for maternity and neonatal services published in March 2023 by NHSE, referred to from here on as the 3 year delivery plan. It sets out how NHSE, integrated care systems and integrated care boards, and NHS trusts will make maternity and neonatal care safer, more personalised, and more equitable for women, babies and families, and will play a valuable supporting role in the implementation of the East Kent recommendations. There are key areas of overlap and opportunities for alignment, including on compassion, culture and safety.

Following an extensive period of engagement, NHSE have asked services to concentrate on 4 themes:

• listening to and working with women and families, with compassion
• growing, retaining and supporting our workforce
• developing and sustaining a culture of safety, learning and support
• standards and structures that underpin safer, more personalised and more equitable care

But the recommendations of the report sit wider than the maternity and neonatal system. The work being done in response to the report will help to engage and integrate wider system partners to jointly address the challenges and issues identified in a co-ordinated and systematic way to help ensure sustained improvement.

What we are doing

There are lots of things already planned or being implemented across maternity and neonatal care nationally that will help to address the issues and challenges highlighted in ‘Reading the signals’, in addition to the new 3 year delivery plan. Further details about those are provided in this response as well as the new things we are doing, as we believe they all play a valuable role in creating the conditions needed for improvements to be successful and sustainable.

Focusing on the new action we are taking, at a national level, the Minister for Mental Health and Women’s Health Strategy will chair a newly created maternity and neonatal care national oversight group. This will bring together the key people from the NHS and other organisations, including the CQC and HSIB, to look across maternity and neonatal improvement programmes and the implementation of recommendations from this and other maternity reviews, to ensure a joined-up and effective approach.

At a local level in East Kent, the Minister for Mental Health and Women’s Health Strategy will convene a local forum bringing together the NHS, CQC and MPs whose constituents have been affected to share information and updates.

While good progress has already been made to deliver some of the recommendations, others are longer term in nature. Dr Kirkup has therefore been appointed to support other government action in relation to recommendations 2 and 3.

Recommendation 1

The 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.

Both the system and trusts themselves need to be able to identify early when a maternity service is vulnerable and at risk of providing unsafe care to patients, so that action can be taken.

To enable that, NHSE has established a Reading the Signals Data Co-ordination Group, referred to in this report as the co-ordination group, who will bring together a series of data projects which aim to make sure the right data will be used in the right way to identify and support trusts who may be vulnerable to bad outcomes. This will employ multiple approaches to make sure that all information that may signal concern is captured. This data will provide more timely and sensitive information to inform the data and intelligence to be shared through the perinatal quality surveillance model. Within the NHS Standard Contract there now exists an obligation on providers to comply with the requirements set out in this model.

An important component of this work has been the establishment of the Maternity and Neonatal Outcomes Group formed by NHSE. This is acting as a task force in response to the recommendation in the East Kent report. Chaired by Dr Edile Murdoch, this group has met and is progressing work towards the identification of these outcome measures that will, as this recommendation states, differentiate signals among noise to display significant trends and outliers. The work will lead to a draft clinical outcome measurement tool that can be used as an early prompt, early surveillance or early screening system in the autumn.

The co-ordination group will bring in other work - for example, a new patient reported experience measure (PREM) that is being developed via the National Institute of Health Research (NIHR). This will be created by 2025 and provide trusts with information on their delivery of quality care. In addition, NHSE and the government are considering the role of artificial intelligence and machine learning in analysis of maternity safety data to explore new insights on potential safety signals, for informing the perinatal quality surveillance model.

While the identification of these signals is key, it needs to be underpinned by action and support.

The NHSE perinatal quality surveillance model is a framework or model that supports the early identification of quality and safety concerns within services, enabling targeted support from the most appropriate level of the system. The model recognises that the trust board is ultimately responsible for the quality and safety of the care provided but also allows the local maternity and neonatal system (LMNS) to escalate concerns to regional groups, who in turn report to the National Perinatal Safety Surveillance and Concerns Group (NPSSCG). This group oversees entry into the Maternity Safety Support Programme, which was formed in 2018 and provides hand-on, bespoke support by NHSE to improve struggling services. The NPSSCG contains a broad membership including the HSIB, NHS Resolution (NHSR), Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries (MBRRACE) and the CQC.

Recommendation 2

Recommendation 2i

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.

The government sees compassionate care as a cornerstone of safe and personalised care. This should be reflected in all encounters, from individual contacts during routine clinical care to supporting women and families following serious incidents and bereavement. We have heard from some of the families affected of how the lack of compassion shown towards them while they were dealing with terrible circumstances made their experiences even more difficult. A failure to listen to women and their families was a key theme in what they told us, with many feeling they had to fight to be heard. This is not only distressing for those having to fight, but it also jeopardises patient safety as Dr Kirkup’s report illustrates.

Dr Kirkup states that compassionate care must be embedded in continuous professional development for everyone at every stage of their career, stating explicitly that this should not simply be learned in the early academic years only to be forgotten in professional life. He sees compassionate care lying at the heart of clinical practice and is explicit about the role of senior role models in fostering this culture.

As part of initial work in response to this independent investigation, the government was supported by the HW Alliance in a mini survey of some of their members. This has allowed us to understand what members see compassionate care as being, and ways this can be facilitated through specific training. These responses are also clear that the workforce needs to be supported with adequate resources for compassionate care to be feasible.

Following discussions with families and patient representatives and drawing on previous safety reviews, we are explicit that the expectation of compassionate care cannot be confined to those providing face to face clinical care. This expectation is on all those who support women and families, whether through the complaints processes, safety investigations, regulatory enforcement or legal process.

DHSC will lead the response to this recommendation in a central coordination role involving relevant national partners, closely supported by NHSE.

We recognise that this recommendation needs to address very different groups of individuals working in often complex systems and are keen to open up this work to healthcare organisations, professional regulators and professional bodies who want to contribute and see changes in this space. This will also include unregulated healthcare professions and the Care Certificate.

Therefore, through commissions to relevant bodies including royal colleges, NHSE, NHSR, regulators and research groups, those involved in complaints and litigation processes, conversations with clinicians and patient representatives and drawing on existing work, DHSC will co-ordinate activity to:

1. Map how compassionate care is currently being taught at all levels and across professions, whether this be formally or as part of in practice training. This will allow us to understand where there are gaps that may be preventing this being embedded and forming a sustained compassionate culture, but also where it is working well.

2. Share good practice and examples of how barriers have been overcome with all those responsible for training, from higher education institutions to those providing preceptorship and clinical supervision at trust level, on the embedding of compassionate care.

3. Identify where gaps depend on national level change or coordination and work with relevant bodies or other government departments to consider how these could be addressed. This will also consider how the government, NHSE and other arm’s length bodies can influence and support sustainable system level change.

While we recognise that this recommendation is not specific to maternity and neonatal care, it is important that compassionate care is an explicit theme in NHS England’s 3 year delivery plan. This is reflected in the significant work that is currently underway or has been implemented since the publication of the report.

In recognition of the need for midwifery training to reflect the currents needs of women and babies, and that good practice is embedded from the very start of undergraduate training, NHSE is currently undertaking a national quality review of pre-registration midwifery education.^{[footnote 1]} The findings will inform the development of the Midwifery Safe Learning Environment Charter for a high-quality placement experience.

Alongside this, recent work by Health Education England (HEE) has highlighted the role of innovative and emerging technologies and other media to support training on compassionate care. The flexibility for approved education institutions to apply this in their training is reflected in the NMC Standards framework for nursing and midwifery education published in April 2023.

In summer 2023, NHSE will publish a standardised framework for what good midwifery supervision looks like, alongside an audit tool that will help trusts to evidence their commitment to ongoing training and supervision. To support this, HEE published its Educator workforce strategy in March 2023 with work ongoing to ensure the NHS has a sustainable supply of educators.

The NMC is about to launch a series of mini campaigns to support the application of the future midwife standards, published in 2020, in recognition that it is implementation of standards and not just their existence that will drive change.

The structures that support doctors’ learning differ depending on the stage of training and employment arrangements. This needs to be taken into consideration when reinforcing the message that kindness and compassion are considered to be core professional competencies rather than an optional part of practice.

The GMC sets the standards and outcomes for medical undergraduates and medical schools develop curricula to meet these. The GMC also approves postgraduate curricula which is developed by the medical royal colleges.

Compassionate care is well embedded in medical education curricula at undergraduate and postgraduate level. This is reflected in the GMC’s Promoting excellence standards and Outcomes for graduates across several outcomes.

From 2024, the GMC is also introducing its Medical Licensing Assessment (MLA). The MLA content map is based on the GMC’s requirements in ‘Outcomes for graduates’ and the Generic professional capabilities framework. The MLA will reinforce expected standards around essential skills, which include communication skills and patient centred care.

The GMC is also updating its core guidance for doctors, Good medical practice, which sets out the standards expected of them throughout their careers. This guidance will include a new, stronger teamworking duty which explicitly states that doctors be role models for compassionate, supportive and inclusive behaviours. This guidance will also incorporate strengthened leadership expectations of all doctors to contribute to more supportive cultures within healthcare. The GMC’s updated core guidance should be read in conjunction with its report Caring for doctors, caring for patients (PDF, 1,941KB), published in 2019, which sets out the 4 domains of compassionate leadership:

• attending
• understanding
• empathising
• helping

It also sets out the behaviours compassionate leaders should display to help translate this into practice.

The government understands the influence of those in senior roles in promoting a culture that facilitates compassionate care at all levels within the healthcare system. The NHS England Culture and Leadership programme, which was rolled out in 2016, provides trusts with a practical, evidence-based approach on understanding of and the steps needed to create truly compassionate and inclusive working environments. Specifically for maternity and neonatal care NHSE will offer by spring 2024 the perinatal Culture and Leadership programme to all senior maternity and neonatal leadership teams in England, including the neonatal, obstetric, midwifery and operational leads. This incorporates a diagnosis of local culture and practical support in co-developing improvement plans to nurture culture and leadership.

It is the responsibility of trusts to tackle any instances of racism or discrimination in the workplace, including for example acting on the principles set out in the combatting racial discrimination against minority ethnic nurses, midwives and nursing associates resource.

The NHSE Long Term Workforce Plan published on 30 June 2023 sets out how we will improve culture, leadership, wellbeing and staff retention over the next 15 years. The plan focuses on implementing actions from the NHS People Plan, improve flexible opportunities and support the health and wellbeing of the NHS workforce.

The Royal College of Midwives (RCM), recognising the need to support midwifery leaders and midwives in the provision of compassionate care through compassionate leadership, developed the Solutions Series in response to the independent Ockenden report of maternity services at Shrewsbury and Telford Hospital NHS Trust.

The Royal College of Obstetricians and Gynaecologists (RCOG) in recognition of doctors as leaders published in 2021 and updated in 2022 the Roles and responsibilities of a consultant. To note this document makes recommendations about the support organisations need to provide to enable consultants to fulfil their leadership responsibilities. This is in line with actions from the Ockenden review accepted by the government. This work is further supported by the RCOG workforce report 2022 which looks to the future on promotion of compassionate leadership.

Dr Kirkup notes the need for compassion in the approach to investigation of safety incidents. This needs to be taken in the context of the complexities that families have faced in navigating the system of complaints, incident investigation and appeal.

The development of the Maternity and Neonatal Independent Senior Advocates for maternity is at pilot stage, with the expectation that these individuals will provide support to women and their families navigating the healthcare system. They will advocate for the families and will be available to families attending follow up meetings with clinicians, particularly where there has been an adverse outcome.

The Patient Safety Incident Response Framework, published in 2022, sets out the NHS’s new approach to patient safety incidents and provides guidance for compassionate engagement with patients and families. The approach prioritises and respects the needs of people who have been affected and substantially improves understanding of what happened, and potentially how to prevent a similar incident in future as a result. The GMC is also reviewing how it engages families and patients in its fitness to practise processes to ensure that it is compassionate and responsive.

For change at local level, it is important for leaders to understand the culture within their own departments. In 2021, the NHS Staff Survey was expanded to include more specific questions around compassionate leadership which will in the future provide trusts with a picture of the progress they have made, but also provide visibility between directorates.

The new CQC assessment framework will continue to consider compassionate care through quality statements that describe what good care looks like. Implementation of the new regulatory model will start in 2023. CQC’s NHS patient survey programme is designed to reflect the experience of particular groups and the care their receive.

NHSR Clinical Negligence Scheme for Trusts’ maternity incentive scheme (MIS) continues to encourage the use of Maternity and Neonatal Voices Partnerships. To further support this, by 2025 NHS England will create a patient-reported experience measure to enable trusts to monitor and improve personalised and compassionate care.

Recommendation 2ii

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.

The report illustrates that not only do clinical and behavioural standards need to exist, be understood and be overseen, they must also be supported by clear and fair mechanisms for their enforcement. These mechanisms should not only be clear to those working to these standards, but to those responsible for enforcing them, and to all of us who rely on the system to support the provision of safe care. The government has heard from families the distress and concern caused where local clinical governance systems have seemed to fail, and where this was not recognised.

Dr Kirkup highlights that despite the existence of long-standing professional standards, there was behaviour in the trust that fell far short of these expected standards.

Implementing this recommendation necessitates defining and distinguishing between the responsibilities of organisations responsible for local, regional and national oversight of care. This in turn needs to consider the professional standards expected of different healthcare professionals, at undergraduate and postgraduate level, who may or may not be engaged in speciality training.

We must also identify barriers to a fair and consistent approach to the use of standards and sanctioning, and where support is needed to make sure this can happen. We know it is important for those working in the system and equally for patients and their families to understand where these responsibilities lie.

DHSC will lead the response to this recommendation, in a central coordination role looking across the whole system. This work will be supported closely by NHSE.

Through commissions from those who work to support and influence the oversight of clinicians including royal colleges, regulators, NHSR, NHSE, NHS Employers and conversations with medical unions, trust human resources (HR) departments, patients and clinicians themselves and drawing on existing work, DHSC will coordinate activity to:

1. Map current responsibilities around oversight and direction. This will include undergraduate and postgraduate nurses and midwives, other healthcare professionals, medical students, trainees, specialty doctors and specialist grade doctors (SAS), locally employed doctors, locums and consultants. This will include identification of good practice, gaps, concerns around transparency and fairness and consider how expansion in the regulated workforce will impact on capacity to support this oversight and direction. This will include exploration of opportunities for co-production of guidance around this.
2. Share good practice and learning on proposed solutions to address gaps in roles and responsibilities in oversight and direction, and support for managing concerns about practice.
3. Identify where gaps in oversight depend on national level change or coordination and work with relevant bodies or other government departments to consider addressing these. This will include examination of where regulators could contribute to identification of poorly performing trusts.

The NMC, GMC and other healthcare professional regulators have a statutory responsibility to set professional standards for all regulated healthcare professionals working in the UK. For the NMC, these are defined in The Code and its underpinning standards, and for the GMC in its core guidance for doctors, Good medical practice, and related explanatory guidance.

It is the responsibility of healthcare regulators to uphold professional standards. They do this in 2 ways. The first is by working with registrants and others to support registrants to uphold the standards. Secondly, where there is a serious failure to observe standards in a way that presents a risk to public protection or public confidence, regulators will take firm but fair action. This may include placing conditions on a healthcare professional’s registration or revoking their registration. Patients and families can raise their concerns directly with professional regulators about individuals.

It is important to note that regulatory sanctions will only apply in the most serious cases. Employers are responsible for supporting staff to meet regulatory standards in the workplace and it is for them role to deal with most instances of poor care.

Employers (generally hospital trusts) should have several options to support them in resolving unacceptable behaviour at a local level. These include local performance management through HR processes and local investigation which could result in the exclusion of professionals from practice while an investigation takes place. Depending on the outcomes of a local investigation, employers have a number of options at their disposal including HR warnings, supervision, changes in professionals’ work patterns, restrictions on practice, periodic suspension and dismissal.

Despite this, Dr Kirkup’s investigation and many that have come before show that employers do not always feel equipped to take early action to tackle shortfalls in the behavioural standards of medical, midwives and other healthcare professionals. Alongside this is the need for medical and nursing directors to be equipped with the skills to address these shortfalls, as should individual supervisors, supported by the workforce directors and boards.

While the professional standards remain the same irrespective of the stage of a clinician’s career, it is their employment arrangements which define responsibility for clinical and educational supervision.

A trust is responsible for employment sanctions for any doctor under its employment. However, the responsible officer for a doctor on a training programme is the postgraduate dean (employed by NHSE), whereas doctors who are no longer in training are accountable to the responsible officer or medical director. These arrangements will differ again for locums where an agency may provide a responsible officer depending on circumstances.

It is therefore essential that organisations representing employers, professional regulators and the royal colleges all work together. Regulators already provide some information to assist employers with this. For example, the GMC provides a Clinical governance handbook which outlines the role that boards and governing bodies should play in governance for doctors, and how this can contribute to high quality patient care. The GMC has also published Principles of a good investigation (PDF, 156KB) to support employers to carry out effective local investigations. It is important that the national framework for managing performance concerns, ‘Maintaining high professional standards in the NHS’, is supported by locally defined standards and is enacted in a way that is proportionate, fair and consistent

In 2018, the NMC published its new strategic direction, ensuring public safety (PDF, 117KB). This was based on evidence gathered during a public consultation and commissioned qualitative research, one of the principles of which is that employers should act first to deal with concerns about a registrant’s practice, unless the risk to patients or the public is so serious that we need to take immediate action.

To support this, the NMC’s Employer Link Service provides training for senior nurses and midwives and trusts on whether a referral to the NMC is needed and offers local support for resolution of concerns. These training sessions also cover what the NMC does to support professionals on its register and provide information about its standards. The NMC also provides additional sessions about The Code and how it works in action.

With specific reference to locums, since February 2023 it has been a prerequisite for short-term locums working as junior or senior registrar in obstetrics and gynaecology to have an NHS certificate of eligibility for short-term locums (CEL). The competencies are aligned with those that would be expected in GMC-approved postgraduate training. To cement its use, CEL is included in the maternity incentive scheme (MIS), as is RCOG safe staffing guidance on:

• the engagement of long-term locums in maternity care (PDF, 864KB)
• compensatory rest (PDF, 379KB) for consultants and SAS doctors working as non-resident on-call out of hours
• compliance of consultant attendance (PDF, 1,514KB) for the clinical situations identified in the roles and responsibilities of consultants document

Practitioner Performance Advice (PPA), delivered by NHSR, provides NHS organisations and the independent sector with support in resolving concerns about clinical and behavioural performance, and is a source of support to trusts, their clinical directors and practitioners. In line with NHSR, maternity is a strategic pillar for PPA. This service works closely with the GMC, BMA and defence organisations to support clear process, consistency and fairness around Maintaining high professional standards in the NHS. However, this support is contingent on trusts, their clinical leaders and HR departments contacting them to seek support.

Recommendation 3

Recommendation 3i

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 the outset.

The government recognises the importance of improved teamwork in maternity and neonatal care and its vital role in patient safety.

Dr Kirkup found evidence of dysfunctional teamworking within and across professional groups in East Kent, which prevented information sharing, and encouraged complacency and lack of accountability. Following discussions with families and patient representatives, we understand that this recommendation is not confined to hospital care and extends to bridging care between the community and the hospital.

We believe, following discussions with stakeholders, that key to responding to this recommendation in a meaningful way is developing an understanding of barriers to teamwork. These are complex and varied. It has been proposed that some of these may be attributable to outdated understanding of roles of obstetricians and midwives. It may also be that the physical set ups of some units inhibit joint handovers, the rotas of junior doctors inhibit continuity of training and supervision, or that teams are not able to release staff to join training. When it comes to clinical practice, the way the health service operates, rota design and the increasing number of locum roles present structural barriers to teams forming, building and improving. It would be helpful for royal colleges to reflect on this with organisations that represent employers, such as NHS Employers.

DHSC will lead the response to this recommendation in a central coordination role, with the close support of NHSE.

Through commissions from relevant bodies including royal colleges, CQC, NHSR, NHSE, HSIB maternity investigations programme, regulators, engagement with those working in healthcare and patients, and drawing on existing work, including CQC inspections, DHSC will coordinate reports that will:

1. Provide evidence through experience and examine existing research on how and where teamwork is being done well. This will include how care pathways are developed and how they are implemented. This will draw together experience from inside and outside maternity and neonatal care.
2. Bring together examples of good practice to support trusts and all those supporting teamwork to utilise as a resource of solutions to barriers and identified gaps.
3. Consider whether, where gaps and barriers are identified, relevant bodies or government can support solutions.

The need for and value of working as a team and multidisciplinary training is well recognised in maternity and neonatal care and is explicit in NHSE’s 3 year delivery plan published in March 2023. The team based approach to training is set as a minimum standard in the modules within the new core competency framework published in May 2023, the compliance with which is incentivised through the maternity incentive scheme. RCM and RCOG continue to advocate for all training at trust level to be multi-disciplinary, which is supported by Donna Ockenden in her immediate and essential actions following her review of care at Shrewsbury and Telford NHS Trust.

To better understand this issue, NHSE is undertaking scoping work with stakeholders to explore what may be possible to improve the interprofessional experience. Given that professional behaviours start to develop at undergraduate level, this work will initially focus on promoting interprofessional experience pre-registration, before moving on to other areas within the career pathway.

The importance of effective teamwork is highlighted within the GMC’s education and training outcomes. For example, the GMC’s Outcomes for graduates states that newly qualified doctors must learn and work effectively within multi-disciplinary teams across multiple care settings, and sets out what they must be able to do to demonstrate this. As mentioned above, the GMC’s updated core medical guidance, Good medical practice, will include a new, stronger team-working duty which highlights the importance of interpersonal relationships, respecting other professionals’ skills and aims to embed psychological safety as central to effective teams.

The need for shared team training is noted by Dr Kirkup in his report. Multidisciplinary training structures such as Practical Obstetric Multi-Professional Training (PROMPT) , Neonatal Life Support, or in house training may help to contribute to an environment of teamwork, as highlighted in the Better births Maternity Review Report. The provision of multi-disciplinary training is incentivised through the MIS that is managed by the NHSR. The MIS supports the delivery of safer maternity care through an incentive element to trust contributions to the Clinical Negligence Scheme for Trusts (CNST).

The RCM Solution Series on human factors provides a structure for self-check-in which provides clear practical tips on teamwork under pressure.

Perinatal Mortality Review Tool (PMRT) framework guidance published in 2018 advises trusts on the importance of multi-disciplinary participation in case reviews. In 2021, the PMRT was used to start a review in 99% of neonatal deaths in England. Although multidisciplinary involvement varied, the framework provides trusts with a clear mechanism for conducting case reviews and who to involve. The use of the PMRT is incentivised in the MIS.

The importance of clearly defined roles within teams has been cited as a facilitator to teamwork (PDF, 637KB), as has the role of individual trust and department culture. The NHS Perinatal culture and leadership programme is being rolled out to directly address these cultural challenges. This is discussed in more detail under recommendation 2i above.

Where teams do require support to identify issues and address them, the PPA can act as an external facilitator and advisor. In keeping with the NHSR strategic pillars, the PPA considers maternity as a priority area. However, as noted above this requires trusts to recognise, issue and seek support.

CQC’s national maternity inspection programme examines team working, looking at how teams work together, train together and learn together. This will also be reflected in new CQC single assessment framework. Implementation of the new regulatory model will start in 2023.

In response to the publication of the final Ockenden report in March 2022 into maternity failings at the Shrewsbury and Telford NHS Trust, DHSC and NHSE established a short-term independent maternity working group (IMWG), chaired jointly by the RCM and RCOG. The IMWG has shared good practice and initiatives, commented on the recommended immediate and essential actions and provided clinical expertise in the NHSE working groups, acting as a critical friend to support delivering positive change for women families and staff. This group has contributed significant expertise across maternity safety focusing on the Ockenden and East Kent reports, with a key component being the demonstration of teamwork at all levels.

Staffing levels can also contribute to poor teamworking when teams are stretched. To help address this it is expected that the target to increase midwifery training places by 3,650 from 2019 to 2020 will have been met this year, alongside expansion in obstetrics and gynaecology training places by 40 in 2022 to 2023 and 2023 to 2024.

Recommendation 3ii

Relevant bodies, including Health Education England,^{[footnote 2]} royal colleges and employers, be commissioned to report on the employment and training of junior doctors to improve support, teamworking and development.

The government accepts that there is a need to improve the support and development for junior doctors. We also understand that the structure and make-up of the workforce is changing, and it is vital that everyone is included in this support. Dr Kirkup specifically notes that there is a need to re-evaluate the changed patterns of working for junior doctors and their impact on teamwork.

As the medical workforce adapts to the needs of the modern NHS, we recognise that training and development needs to include those inside formal postgraduate training schemes, those who are seeking to progress to certificate of eligibility for specialist registration outside these training structures, those who are working as speciality doctors, and those who are working towards roles as specialist doctors, locally employed doctors and locums at all levels. These groups will have different relationships with the trusts in which they work and respective royal colleges. By 2030 it is projected that 30% of doctors below consultant level in obstetrics and gynaecology will be SAS and locally employed doctors.

DHSC will lead the response to this recommendation and be supported closely by NHSE.

Through commissions by DHSC to relevant bodies, including medical royal colleges, the National Guardian’s Office and those working in healthcare, DHSC will coordinate reports that will:

1. Map how the support for junior doctors, and those who have yet to complete training including locums, is translated into practice, what access they have to development and how teamwork is embedded within this. This would include trust level considerations around rotas and impact on teamwork and will consider regional and national programmes.
2. Identify and share good practice and learning around proposed solutions to address gaps in roles and responsibilities for supervision for specific groups.
3. Consider whether the government and its arm’s length bodies (ALBs) need to provide support to the system to address gaps and barriers.

The need for structured support is recognised by those responsible for training and remains under constant review. Whether a junior doctor is in formal training or not may define where and how they are supported and access to professional development.

For doctors in postgraduate training, the medical royal colleges and faculties design the curriculum, and the GMC approve it. However, the need for reform has been recognised by the GMC. In response to calls for urgent reform of training by patients, doctors and employers in 2017, the GMC published Adapting for the future: a plan for improving the flexibility of UK postgraduate medical training. The ambitious vision for reform was supported by the Generic professional capabilities framework. While this relates to postgraduate medical education and training, it was expected to support all phases of UK medical education and continuing professional development.

The Conference of Postgraduate Medical Deans’ Gold Guide sets out a framework with clear principles for the operational management of postgraduate training to support consistent decision making by postgraduate deans and their support structures on training needs and support. In addition to this, HEE has practical supervision guidance in the Enhancing Supervision in Postgraduate Training handbook in response to concerns raised by trainees as part of Enhancing Junior Doctors’ Working Lives programme (EJDWL). EJDWL was established in 2016 and continues to provide meaningful change to the system.

We are aware that access to local or regional teaching and training, funding or clinical cover for study leave will vary greatly for locally employed and SAS doctors. The local employment arrangements for trusts vary. In response to calls for better support for SAS doctors, NHSE has established SAS leads, and in 2017 the Academy of Royal Colleges, the BMA, HEE and NHS Employers published a SAS doctor development guide (updated in 2020). In 2019, HEE published a document outlining essential measures to support SAS doctors. Similarly, this arrangement would then differ again for locum doctors and locally employed doctors.

For all junior doctors we need to acknowledge that while guidance exists on access to development and support it is not always implemented. This is also the case with meaningful induction to trusts and new departments to allow those in new roles to be welcomed, identifiable and supported. We do know this is being done well in many areas. However, we know in some trusts and deaneries there are barriers to this, noting that initial conversations have pointed to the main barrier currently being staffing shortages.

Recommendation 4

Recommendation 4i

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.

Recommendation 4ii

Trusts be required to review their approach to reputation management and to ensuring there is proper representation of maternity care on their boards.

Recommendation 4iii

NHSE reconsiders its approach to poorly performing trusts, with particular reference to leadership.

Healthcare professionals and healthcare bodies must be honest and transparent with patients, their families and with other bodies. This requirement is referred to as the ‘duty of candour’ and in most healthcare settings it is respected and upheld. However, it’s clear from this report that some of those involved in East Kent did not adhere to the duty of candour. This left families without answers or even feeling deceived by those working in a system in which they placed so much trust. This should never be the case for anyone who is seeking answers from those who have responsibility for caring for them.

We received feedback during our discussions with the families and some other stakeholders that there is concern and a perception that trusts and individuals are being hindered in their ability to be fully transparent by legal advice, or through reputation management strategies. It is also clear to us from those discussions that a duty of candour is not satisfied just by a single, one-off candid conversation, but should underpin the whole of the process of supporting and working with families, at every stage.

The existing legislation that supports this transparency is the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which introduced this statutory duty of candour for every health and social care provider that CQC regulates. The duty of candour requires registered providers and managers to act in an open and transparent way with people receiving care or treatment from them.

In addition, the Care Act 2014 introduced a new offence in relation to the provision of false or misleading information.

When a notifiable patient safety incident occurs in the course of a patient’s care, NHS organisations are legally required under a statutory duty of candour to:

• act openly and transparently
• provide patients with an accurate account of what happened
• apologise

When reviewing trusts, CQC looks at culture, and how and whether this duty is being delivered. CQC can take enforcement action against a provider for breaching the regulations.

The government acknowledges the failure to adhere to this duty of candour that was so evident in this report and recognises the need for action in this area in order to make sure the duty is effectively applied and to create a culture of candour throughout organisations. For maternity and neonatal care, we have set out our approach to creating a culture of honesty, compassion and safety through the 3 year delivery plan. This includes the perinatal culture and leadership programme which provides a diagnosis of local culture and practical support to all units. That is accompanied by clear expectations of trusts to maintain an ethos of honest reporting and sharing of information, regular reviews of the quality of their services, and listening to and acting on feedback from staff including freedom to speak up (FTSU) data. Trust boards are expected to support a focused plan to improve and sustain culture, including alignment with their FTSU strategy and ensuing all staff have access to FTSU training and a guardian who can support them to speak up.

Alongside this, our new Patient Safety Incident Response Framework (PSIRF) will be embedded in trusts by autumn 2023. PSIRF is a contractual requirement under the NHS Standard Contract and as such is mandatory for services provided under that contract. The framework sets out requirements for providers to work compassionately with those affected by an incident. This may help to alleviate some of the harm caused and facilitate understanding and learning from what went wrong. These requirements include the legal expectations of duty of candour and meaningful engagement and involvement of service users and staff. During 2023, NHSE will support the implementation of PSIRF in maternity and neonatal care with national learning events.

When considering the broader recommendation made by Dr Kirkup for a bill to place a “duty on public bodies not to deny, deflect and conceal information from families and other bodies”, the government will set out its position in response to Bishop James Jones’ 2017 report on the experiences of the families bereaved by the Hillsborough disaster in due course.

The government believes that this transparency should extend to clear understanding of the processes for families to have their voices heard, for them to access redress and where they can find independent support. This would need to include a clear understanding of where families and staff can turn if these systems are not working as was the finding in this report. When women and families do have concerns and would prefer to discuss these with someone not involved in their care, their local Maternity Voices Partnership (MVP) or the Patient Advice and Liaison Service (PALS) can offer advice and support. These mechanisms must be accessible, and families need to be aware of them. It is expected that the implementation of the role of the Independent Senior Advocate, which was an action from the final Ockenden report, could strengthen this. The rollout of this post is still at pilot stage and pending review.

In relation to reputation management, the NHS should be open and transparent with everyone using NHS services. That is supported by the guidance on the professional duty of candour from the NMC and GMC. Concerns in relation to openness and transparency are considered a safety issue, as made clear in the report. Addressing these concerns forms part of the expectations of a well led and well governed organisation which are set out in the NHS oversight framework. In the case of the most challenged trusts, support to address the underlying leadership and governance issues will be provided via the Recovery Support Programme (RSP).

Shortly after the publication of the report, NHSE asked all trusts and integrated care boards (ICBs) to review all of the recommendations - including this recommendation to review their approach to reputation management - at their next public board meeting.

The CQC, as part of its new regulatory model, will continue to consider trust leadership at executive team and trust board level as part of the well-led key question in its single assessment framework. This will continue to include duty of candour and how a provider ensures it is fulfilling its responsibility to carry out all aspects of the duty.

Work since the publication of this report has revealed some of the factors that it is felt inhibit transparency and openness. These include how legal advice to trusts is used around serious incidents and culture embedded when performance of trusts was solely target driven.

Recommendation 6 in the Messenger review, that has been accepted by the government, and to which NHSE is responding, states that “the NHS must achieve greater diversity so that NED [non-executive director] and chair roles more closely reflect the communities they serve and the staff they govern”. When achieved and sustained it may in turn facilitate openness within the trust and communication with communities the trusts serves.

The government knows the importance of proper, meaningful and skilled maternity representation on trust boards via the maternity and neonatal board safety champions. We expect these maternity and neonatal board safety champions to be fully supported by the trust board.

We recognise the significant role that maternity and neonatal safety champions should be playing at frontline and board levels. This acts to safeguard good and undiluted ward to board communication on maternity issues.

Since the publication of this report NHSE have made more explicit the nature of proper representation at board level. The NHSE 3 year delivery plan clearly sets out how maternity and neonatal services should be represented at trust board level. Trusts should “appoint an executive and non-executive maternity and neonatal board safety champion to retain oversight and drive improvement. This includes inviting maternity and neonatal leads to participate directly in board discussions”.

Representation through both executive and non-executive safety champions is incentivised through the NHSR maternity incentive scheme. Guidance and a toolkit to support maternity and neonatal safety champions, including those on trust boards, have been developed to enable them to deliver best practice. However, this does not yet include explicit reporting on the involvement of leads in board discussions.

We know from discussions with stakeholders that the role and quality of board safety champions can vary significantly between trusts. NHSE has worked with board safety champions both pre- and post-publication of the report to better understand the challenges faced by this group, and what support could be offered to ensure individuals are enabled to undertake this role to the best of their ability.

A major theme to emerge from this engagement was the challenge of meaningfully using the existing and emerging datasets on maternity and neonatal care. To address this, in the 2023 to 2024 financial year, NHSE is commissioning a support programme for board safety champions to focus on developing the leadership, culture and processes needed for them and their teams to be able to use qualitative and quantitative data to improve maternity and neonatal safety in their organisations. This will include the need to be curious and transparent with their data.

NHSE is also updating the toolkit to be more explicit about the difference in roles and responsibilities of the executive and non-executive board safety champions, as they are, and should, be very different. The toolkit will recognise the importance of collaborative working between the service level and board safety champions to enable an honest representation of maternity issues and best practice at board. It will also support the maternity and neonatal service level champions having a direct voice at board, rather than information solely being presented via the board safety champion.

The government recognises the importance of considering how poorly performing trusts are supported. The appropriate support is needed for trusts to access additional expertise and resources to ensure improvements are made as soon as possible. It is important that the government sees improvements that are not only implemented but, more crucially, they are sustained.

A key part of NHS England’s support on leadership for the most challenged trusts is via the Recovery Support Programme, whereby experienced improvement directors work with boards and executives on areas of leadership, governance, culture and staff engagement. NHSE continuously assesses the effectiveness of the approach taken in the RSP and has recently commissioned a formal rapid evaluation via the NIHR, which will help inform NHSE’s longer-term response to this recommendation.

NHSE is already responding to 2 reviews that address trust leadership that we believe will also address this recommendation.

The recent Messenger review examined leadership in the NHS. Recommendation 7 of the review describes the need to encourage top talent to work in challenged parts of the NHS, which will act to support these vulnerable trusts. The government accepted all the recommendations from the Messenger review and NHSE is in the process of responding more generally .

In response to the Kark review of the fit and proper persons test (FPPT), NHSE has established a steering group to implement recommendations 1 to 4. These recommendations address:

• competence of executives and non-executives to sit on the board
• that a central database of directors be created
• that there are mandatory reference requirements for directors
• the extension of the FPPT to ALBs

The steering group will not only provide a mechanism to review progress on delivery but will take into account inputs from expert advisory panels and whistleblowers. As part of this work, a FPPT framework with guidance will be developed to support its application. It is hoped that this rigorous application of these recommendations will allow the FPPT to be adapted to ensure better leadership and management, and prevent employment of inappropriate directors.

NHSE has powers regarding the replacement of trust leadership which it uses in extreme and exceptional circumstances, and applies fairly, reasonably and proportionally, and with the interests of those served by the trust in mind. Many vulnerable hospitals suffer with lack of permanence of leadership which in some circumstances will act to exacerbate issues. In many circumstances it is more appropriate to support those who are there to oversee change of often longstanding and engrained cultures.

While interventions to support vulnerable trusts are key to improvements, the government will work with NHSE, through the co-ordination group outlined in response to recommendation 1, to make sure these mechanisms do not wait for harm to be done before action is taken.

Recommendation 5

That the trust:

• accepts the reality of these findings
• acknowledges in full the unnecessary harm that has been caused
• embarks on a restorative process addressing the problems identified, in partnership with families, publicly and with external input

On receiving the report on 19 October 2022, the trust apologised unreservedly and publicly accepted all of the findings. They have a clear determination to use the lessons within it to make the improvements needed in order to consistently deliver the safe and compassionate care local communities should expect. The trust recognises that learning from the report is relevant to the entire trust and have acknowledged that previous efforts to tackle some embedded problems have not been successful.

On 21 October 2022, the trust board held an extraordinary board meeting attended both virtually and in person by families, members of the public and the media, and formally accepted the report in full and committed to addressing the areas for action in the report and the recommendation for the trust. The trust also discussed the report and its findings in public meetings of its Council of Governors, local health overview and scrutiny committee, and all subsequent public board meetings.

In February 2023, the trust set out its response to the report which was published alongside an open letter of apology to the public and shared with every member of staff. These immediate, short and long-term actions include improving how they listen to and involve patients and families and specific, focused work in maternity to improve safety, as well as work being taken forward across the trust.

The board will be responsible for overseeing this major transformation programme with day-to-day responsibility for delivery and monitoring progress taken forward by its clinical executive management group. Specific improvements in maternity and neonatology services will continue to be overseen by a maternity and neonatal assurance group, again reporting to the trust’s board.

Specifically, the trust:

• has set up a ‘Reading the signals’ oversight group which includes families who were involved in the independent investigation, the local maternity and neonatal service, MVP, ICB and NHSE colleagues and the trust’s Council of Governors. It meets in public and reports directly to the board of directors. It provides oversight of the trust’s response to Reading the signals and makes sure there is appropriate engagement with patients, their families and the community to oversee, challenge and advise on how the trust embarks and embeds the restorative process required to address the problems identified in the report
• has established an independent case review process. Families who have concerns about maternity or neonatal care they received from the trust are offered the opportunity to meet with or speak to experts independent of the trust, regardless of whether their care had previously been reviewed or investigated by the trust
• has so far held discussions with more than 4,500 women about all aspects of their and their baby’s care, giving opportunities for staff recognition, learning and action. Through an initiative called ‘Your voice is heard’, all maternity service users, and their partners, are offered a 30-minute follow-up call to discuss their experiences 6 weeks after giving birth. There are clear action plans to address feedback - for example, provision of improved facilities for partners and a pain management group with pain control training for staff with additional options such as TENS machines to improve pain management. This work is supported by 2 patient experience midwives recruited specifically to improve the experience of families and was co-designed with the local MVP
• has developed a new bereavement pathway. Specialist bereavement midwives have worked with families and SANDS, the saving babies lives charity, to improve and expand the emotional and practical support provided to families. This includes any subsequent pregnancies, labour and delivery and has resulted in a new model of care which includes a newly recruited team providing a 7-day service
• as part of the commitment to nurture compassionate leaders and effective teams that work well together, is adopting NHS England’s Culture and Leadership Programme developed by the Kings Fund. This programme has been introduced elsewhere in the NHS and there are proven links between compassion in healthcare and outcomes for patients. It is aimed at all levels in the trust and has recruited 110 change champions across the trust by summer 2023
• is creating an organisational culture which feels psychologically safe enough to speak up, learn and improve in. The trust expanded its freedom to speak up (FTSU) team by appointing 4 dedicated FTSU guardians, one specifically for maternity, and 20 FTSU champions who have been proactive in raising the visibility of the service. They have seen a 269% increase in people contacting them (155 times in 2022 to 2023). Feedback is being used in mandatory training and is being used with other information to identify and support areas of risk
• has implemented a rapid incident review process to ensure that potential serious incidents are formally highlighted, and immediate safety improvements have been actioned. The Kent and Medway ICB is supporting the trust to engage external clinical experts to undertake case reviews
• has recruited a new experienced, substantive director and deputy director of midwifery who started in post in mid May 2023 to provide strengthened maternity leadership and support further improvements to the service across the trust
• as part of dying matters week in May 2023, has made a caring with compassion video. The film features trust staff and was funded by the East Kent Hospitals charity. The video is being used in mandatory training for all trust staff and is one of the commitments made in response to ‘Reading the signals’

The trust has received intensive support from NHSE National Intensive Support Team, Southeast NHSE regional team and the Kent and Medway ICB within an aligned improvement support approach.

The trust recognises that sustained, long-term change takes time and is committed to working with external partners, and with patients and their families, to deliver the safe, high-quality care their communities expect.

Next steps

We will continue to work collaboratively across the health service, with those who work in it and patients who rely on it as we implement these recommendations and deliver on the commitments made in this response. We remain fully committed to learning and improving the provision of maternity and neonatal care. This response is one step within a longer journey which is already underway.

Progress on implementation of the recommendations will be monitored through NHSE governance routes and by the department, directly accountable to ministers. This includes through the newly established national oversight group.

1. For the purposes of this response where work was done by Health Education England (HEE), we will refer to them in this capacity. However, future and current work will be referred to as being led by NHSE as HEE merged with NHS on 1 April 2023. ↩

2. For the purposes of this response where work was done by HEE, we will refer to them in this capacity. However, future and current work will be referred to as being led by NHSE as HEE merged with NHS on 1 April 2023. The recommendation wording is taken directly from the ‘Reading the signals’ report published before this merger. ↩