What is the Kirkup report?
The Kirkup report is an inquiry into maternity services at East Kent Hospitals University NHS Foundation Trust (East Kent). The inquiry examined services at the Queen Elizabeth The Queen Mother Hospital in Margate and the William Harvey Hospital in Ashford from 2009 to 2020.
It was commissioned in 2020 and lead by Dr Bill Kirkup who had previously reported on the maternity failings of Morecombe Bay and Furness General Hospital, Cumbria.
The review was instigated after several episodes of poor maternity care came to light, including mistakes during the delivery of Harry Halligan in 2012, and the tragic case of Harry Richford, who died after he was born in 2017; he was just seven days old.
More than 200 families came forward with concerns about the maternity care they had received at East Kent.
The report follows the Ockenden report published in March 2022 regarding the maternity failings at Shrewsbury and Telford NHS Trust.
The findings
The review found that had care been given to nationally recognised standards the outcome could have been different in 97 (48%) of the 202 cases assessed and in 45 (69%) of the 65 baby deaths investigated.
The review identified 4 areas of concern:
- Failures of teamworking
Staff members were unprofessional, were disrespectful to other staff in front of women, were disrespectful to women and blamed women when something had gone wrong.
- Failures of compassion
Staff delivered care without compassion including dismissing women’s concerns and making insensitive comments during deliveries.
- Failures to listen
There was a failure to listen to women’s and family’s concerns such as a reporting of reduced foetal movements. The review found that in some cases the failure to listen contributed to a poor clinical outcome.
- Failures after safety incidents
When something had gone wrong, staff failed to show compassion, denied responsibility for what had happened and wrongly blamed the mother.
The report highlighted that one of the reasons the serious failings within maternity services at East Kent occurred was because several external reports highlighting problems to be addressed were ignored.
This included a Royal College of Obstetricians and Gynaecologists (RCOG) review in 2016 which found significant problems across East Kent’s maternity services. This review led to a maternity improvement plan.
In 2018, the Healthcare Safety Investigations Branch found failings in the East Kent maternity services.
During the inquest of Harry Richford in 2020 it emerged that East Kent had failed to complete 21 recommendations made by the RCOG in 2016.
The Kirkup report demonstrates that the failings and recommendations highlighted by the 2015 report into maternity services at Morecombe Bay were not implemented by other NHS Trusts. It is hoped that this will now change as it is clear from this report, and several others, that inadequate maternity care is not limited to one Trust.
The report has identified four areas for action for the NHS. It must be better at:
- Identifying poorly performing maternity units.
- Giving care with compassion and kindness.
- Teamworking with a common purpose.
- Responding to challenge with honesty.
The report can be found here – Kirkup report
What will be the outcome?
It is hoped that maternity services not only at East Kent but across the whole NHS will improve following the Kirkup report. An investigation has recently started into the maternity services in Nottingham, and more than 700 families and 160 staff have contacted the review team to date. A new CEO has recently been appointed to Nottingham University Hospitals NHS Trust, and he has apologised to the “families who have suffered as a result of the mistakes that have been made”. He states that he will make improving maternity services in Nottingham his first priority.
Serious complications and deaths resulting from failures in maternity care whether the harm is suffered by mother or baby have devastating and lifelong impact on families and their loved ones.
At Moosa-Duke Solicitors, we hope that the Kirkup report and other maternity inquiries will initiate change and improvements to maternity services across the NHS.
If you have concerns about the maternity care that you or a family has received, please contact our specialist team for a no-obligation consultation on 0116 254 7456 or at enquiries@moosaduke.com.