Published 25 October 2022
Updated 1 December 2022
The following statements were given by our chair, Niall Dickson, and our Council of Governors, at an extraordinary Board meeting on Friday, 21 October, to receive the report by Dr Bill Kirkup following the independent investigation into our maternity service.
Our enquiries line closed on 30 November, but you can still contact us through our PALS team if you have questions or concerns and a member of our maternity team can arrange to call you or answer your questions by email.
Statement from chair Niall Dickson
Thank you for attending this special meeting of the Board of East Kent Hospitals. As you know on Wednesday the independent Investigation commissioned by NHS England published its report into our maternity services between 2009 and 2020. This open Board meeting will give the senior management team an opportunity to outline its first considered reaction to the report, and the Board an opportunity to reflect on that and the next steps the Trust needs to take in response.
We are also joined by our Council of Governors which is part of the structure of Foundation Trusts – our governors are independent and it is to them that I and my fellow non-executive directors are responsible.
I should make clear that this is the start of a process not the end. The Board will be meeting again early in November when I hope we will have developed our thinking further and have at least started to shape how we will begin the journey to make sure the failings identified in this report are not repeated.
As I am sure most of you know the Trust gave an initial response two days ago when we first received the report.
This is a shocking account - in the words of its author both deplorable and harrowing. It describes a litany of failures and missed opportunities which have left families in our local communities devastated and with emotional scars that will never heal.
We have said sorry and on behalf of this whole Board I say sorry again now, but of course saying sorry is meaningless unless we are prepared to learn lessons and bring about change.
It is a shocking report not only because of clinical failings and technical mistakes that were made time and again but also because of the way our clinical staff behaved towards mothers and their families and the way management and the Board engaged in a repeated ritual of defence and denial.
Initial errors were made on the front line – poor clinical decisions leading to sub-optimal care, failures to escalate, failures to respond when escalation did take place, poor inter professional relationships, mutual recrimination and an apparent inability to listen to mothers and their families.
But the failure goes beyond this. The way we reacted when things went wrong compounded those front-line errors. Too often the senior levels in this organisation, including the Board, were in effect complicit in cover-up and denial. The instinct to defend the reputation of the organisation trumping the need to question and understand what had actually been going on.
The report itself is unusual in not providing detailed recommendations – there have been plenty of those in the past - but it does make clear in its final words and I quote ‘the new leadership of the Trust will read this report and can see exactly what has gone wrong and what needs to be put right’.
That is indeed our challenge.
There are four areas for action – first learning how to monitor safe performance – finding signals above the noise.
Personally, I think this is critical and I am not sure at this point we have the answers. The report suggests a Task Force at national level to introduce valid maternity and neonatal outcome measures but I hope we can establish ways of creating a canary down the mine ahead of that. And we need that data across the work of the Trust.
Secondly – standards of clinical behaviour – technical care not being enough. There is a Yin and a Yang within medicine and nursing - there is the science and the art, there are proven interventions but there must always be kindness, compassion and empathy and they are of equal value – the one without the other is worthless.
Today and every day the vast majority of patients in our hospitals will experience great care, compassionate care, technically brilliant care – as they should but the evidence from this report is that it is not consistent. We are not kind all the time to our patients or indeed kind to each other.
Thirdly - flawed teamwork – this was evident in the report on Shrewsbury and Telford. I saw in the first maternity safety report we commissioned when I was at the King’s Fund 14 years ago which exposed damaging divisions and tensions between midwives and obstetricians.
My impression is that we have made some progress on this in the Trust since the period covered by the investigation report but surely not enough. To work together professionals must learn together. We can no longer tolerate fiefdoms.
And area Four - organisational behaviour – looking good while doing badly.
It is the instinct of leaders in any organisation to want to do well and to be seen to do well. Healthcare organisations are no different. Those in senior positions are vulnerable – failure to perform can result in dismissal and end of careers. But changing cultures takes time and consistent leadership. Revolving doors seldom deliver.
We need to commit to being honest and open – that much is clear. We will get it wrong – we and our clinical colleagues will make mistakes but can we make a pledge that from this moment on we will be open, we will be frank, we will be honest and we will be forthcoming.
There is an irony at the heart of our deliberations today – as the report suggests the failings here – and we have to assume elsewhere – are obvious and in some ways quite simple – but transforming an organisation of this size and complexity, changing expectations and behaviours is not straightforward and in so doing we need our staff to feel good coming to work, we need to support them not blame them.
As I said a moment ago, our promises and good intentions will mean nothing if we repeat the patterns of the past. We need a reset, we need to engage with all our staff we need to challenge poor behaviour and we need to listen to and work with patients and their families like never before.
This is a challenged organisation we have very real financial challenges, staffing challenges and a crumbling estate. We must tackle each of those as best we can but as the report says they cannot be an excuse for a culture which has tolerated the behaviours outlined in this report.
Statement from lead governor Bernie Mayall on behalf of the Council of Governors
Like many, we, the Council of Governors have read the heart-breaking testimonies in the Kirkup report and the very difficult conclusions it draws. Though words are pretty inadequate at this time, our thoughts are with all of the families who have been so badly let down by the Trust.
The Council of Governors is an independent and voluntary group of individuals, elected by Trust members in our constituencies to represent both the people using and those working in the Trust. It has a number of statutory duties including to hold to account those tasked with running and managing those services. Our independence is priceless, and allows us the freedom to challenge and probe, offering us a range of unique insights into the Trust. Though much more will be said we wish to offer the following thoughts.
Firstly, to the families. We would like to thank you and recognise the enormous courage and tenacity you have shown in sharing your experiences. We note that of the 202 families who took part in listening sessions, many took up the opportunity of counselling afterwards. This shows both how harrowing an ordeal it was, and that there was a clear need for more support much earlier. That need for support remains and we expect the Trust to deliver it.
To Bill Kirkup and his team, thank you for the painstaking and challenging work you undertook completing this investigation. It was difficult to read and must have been even more difficult to write. We note the call for greater public accountability, along the lines of the “Hillsborough law” and we wholeheartedly agree. We will also ensure we keep recommendation 5 absolutely at the heart of all our future endeavours. This states that:
“The Trust accept the reality of these findings; acknowledge in full the unnecessary harm that has been caused; and embark on a restorative process addressing the problems identified, in partnership with families, publicly and with external input.”
I would also like to introduce and mention my colleague, Nick Hulme, who features in the report and has been a driving force behind the scrutiny we place on the Trust and the plans and improvements that are already underway. He became a governor as a result of his own experience of East Kent Foundation Trust maternity care when his first child was born, determined to do all he could to reduce the risks for others. He has been incredible.
The Council of Governors has long raised issues and challenges around what the report terms a culture of “looking good while doing badly”, the obfuscation and denial, the toxic environment, and we have faced the barriers described in the report.
Like many of the external bodies the report mentioned, the Council of Governors was denied access to data, documents deliberately subjected to concealment, Governors dealt with a lack of integrity and respect, and the Trust openly harassed people who challenged them. Trying to obtain detail, facts, and information, was made impossible. The report confirms what we knew but the obstruction by the Trust management made it impossible to prove.
Our duty extends to those employed by the trust, as well as patients, and we always suspected people working in the Trust were too scared to take formal action when they were bullied and it is likely that good, decent staff were lost as a result. We saw it and I have to say we also experienced it.
The report also states that previous changes of senior leadership were problematic when “enthusiasm for the newly appointed individuals created unrealistic expectations”. The governors remain mindful of this, however our new Chair, Niall Dickson, appointed in February of last year and new CEO Tracey Fletcher, appointed in December of last year – appointed by the Council of Governors – have made a positive start even before the report was published, and we are optimistic the environment is slowly changing.
However, there is still an enormous task of changing the whole ethos and culture of the Trust. The report has exposed what needs to be done and has at last shone a light into the dark corners of this Trust. While recognising that some things will take more time, we will be expecting and demanding some immediate changes, visible evidence that this time it is different, a marker that distinguishes the “then” from the “now”. We will expect this to continue at pace, the momentum to be kept up, and the evidence of improvement delivered to the Council of Governors.
To the wider public we wish to say that every Governor wants to hear from people, those using the services and those working for the Trust. Please reach out to us if you want or need to talk. This report gives us a new freedom to challenge and to drive improvement on your behalf.
Please also consider becoming a member of the Trust. That gives you a say in what happens and makes it easier to impact the Council of Governors.
I just want to end by thanking the families again, with a full heart. You should never have had to go through what you have been through and we are grateful to you for the grace and the courage you have shown to bring us to this point. This report – your courage - gives us the opportunity to make the impact we need and want to make, to grasp this appalling nettle and uproot it.
And as a Council of Governors we make a promise to you and to the people of East Kent, and the staff in the Trust, that we will be steadfast in this journey, will drill as deep as we have to, support and partner with the people tasked with this job, challenge as hard and as vigorously as we need to. We will use every tool we have to demand that the people responsible will be made accountable and that any remaining vestige of toxicity is cut out of the Trust. The people of East Kent deserve better.
Council of Governors background:
The Council of Governors has a number of statutory duties, including appointing the Chairman and Non Executive Directors and ratifying the appointment of the Chief Executive. The Council of Governors also determines the remuneration and terms and conditions of the Chairman and Non Executive Directors, receives the Trust’s annual report and accounts and auditor’s report, and appoints the Trust’s external auditor.
The public and staff members of the Council of Governors are elected from the Foundation Trust membership by the members and serve for terms of office between two and three years. The Council of Governors also consists of nominated representatives from key stakeholder organisations.
Council of Governors is an independent and voluntary group of individuals, they are not paid and give up their spare time to undertake this work. We currently consist of 15 Governors from a variety of backgrounds. We currently have four Governor vacancies.
For more information visit: https://www.ekhuft.nhs.uk/patients-and-visitors/about-us/boards-and-committees