Reading the Signals: A series of failures in NHS Maternity Services

Staffordshire and Telford Hospital Trust - Independent Maternity Review

Morecambe Bay Investigation

Reading the signals: Maternity and neonatal services in East Kent

A report into maternity services in East Kent published in October 2022 highlights a cycle of endlessly repeating one-off catastrophic failures. This report comes after independent reviews identifying systemic failings at Morecombe Bay review in 2015, in the Shrewsbury and Telford Hospital NHS Trust in 2022 and the ongoing review of maternity services in Nottingham University Hospitals. 

These reports highlight repeated examples of maternity and neonatal services in England that are failing to deliver safe care, and of avoidable harm and deaths. At the core of this the reports show parents are being failed, and staff are being bullied. The report into East Kent identifies eight missed opportunities between 2010 and 2018 where there were chances for the Trust Board, regulators, or other bodies to act. The report documents a sustained culture of toxic leadership and bullying, which the Trust were aware of and failed to resolve. The East Kent report author, Dr Kirkup, said 45 of the 65 baby deaths reviewed could have had a different outcome. In Dr Kirkup’s 2015 report on Morecombe Bay Trust the deaths of eleven babies and one mother were said to be avoidable.

‘Reading the signals…’ makes for distressing reading, especially as people who spoke up and ‘blew the whistle’ were ignored and / or victimised, and the wider picture was missed by the commissioners, professional bodies and by regulators. This meant that actions and learning essential to prevent avoidable harm were not taken, with the trusts treating both staff and parents who raised concerns with contempt. The report into East Kent contains a powerful example of this. After anonymous reporting of bullying, the NHS Trust agreed to a review of the staffing within the department. When this review recommended a number of senior midwives be relocated or suspended the Trust removed its support. This led to the Head of Midwifery at the Trust resigning.When she went to the Royal College of Midwives (RCM) she received the following advice on whistleblowing

“Advised against disclosure in the interests of patient safety because of the risk this posed to her future career prospects.”

“Advised them to resign and move on; if not … they would be unemployable in a senior position, and they should protect themself.”

“Whistleblowing was not in the public interest and they had to think of their career.”

- Reading the signals Maternity and neonatal services in East Kent

(The Report of the Independent Investigation)

The report goes on to show that, following the resignation, the abusive culture within the Trust’s maternity unit continued unabated. It is apparent that this failure was the result of a toxic culture endorsed from the top down by leaders and professionals ignorant of their duty of care and responsibility to protect whistleblowers.

Steve Turner, facilitator of the WBUK Healthcare Focus Group comments:

‘An Office of the Whistleblower would have prevented a patient safety matter becoming an employment issue, by providing a safety net to everyone who raised the alarm about the safety of patients at the outset. In addition, an independent Office of The Whistleblower provides the stimulus and opportunity to look across organisations and hierarchies, to examine root causes, and intervene early. As a result, everyone benefits. The cost of ignoring whistleblowers is simply too high, it is time to introduce proper measures regulated by an Office of the Whistleblower to join the dots, examine underlying themes openly, and put a stop to avoidable deaths of babies and mothers in maternity units across the UK.,