Reading the signals: maternity and neonatal services in East Kent - the report of the independent investigation. 2022. (accessed 27 October 2022)

NHS England. Terms of reference: Independent maternity review – Nottingham University Hospitals NHS Trust. 2022. (accessed 27 October 2022)

Nursing and Midwifery Council. NMC statement in response to publication of the East Kent maternity review. 2022. (accessed 27 October 2022)

Ockenden report - final. 2022. (accessed 27 October 2022)

Preventing needless deaths in maternity care

02 November 2022
Volume 30 · Issue 11

It is hard to imagine how devastating it must be to lose a child. It must be especially difficult to learn that a baby's death could have been prevented. However, according to the findings of the recently published independent review into maternity and neonatal services in East Kent (Kirkup, 2022), this has happened to many families, whose accounts were collected for the report.

As Dr Bill Kirkup notes in his open letter that begins the review, this is the second review published this year to highlight service failures in the UK, with the final Ockenden (2022) report having been released in March this year, following the investigation into maternity services at The Shrewsbury and Telford Hospital NHS Trust. A third review has since been commissioned at the Nottingham University Hospitals NHS Trust, which began on 1 September this year and is expected to last 18 months (NHS England, 2022).

Dr Bill Kirkup's (2022) report breaks with the norm for these independent investigations. Rather than recommending specific changes to particular practices or management policies, Dr Kirkup has instead identifed four ‘areas for action’ for the NHS as a whole. These four areas, ‘monitoring safe performance’, ‘standards of clinical behaviour’, ‘flawed teamworking’ and ‘organisational behaviour’, each include specific recommendations to address the issues outlined.

Responding to the report, Andrea Sutcliffe, chief executive of the Nursing and Midwifery Council (2022), said ‘it's clear that women and families receiving care were not listened to or treated with compassion’. Indeed, Dr Kirkup's second recommendation is that there need to be reports on how compassionate care can be embedded into practice and sustained, calling on Royal Colleges, professional regulators and employers to establish how oversight and direction can be improved.

Dr Kirkup acknowledges that addressing the areas for improvement that his report highlights will not be ‘easy or necessarily straightforward…But unless these difficult areas are tackled, we will surely see the same failures arise somewhere else, sooner rather than later’.

It is a chaotic time, both in the UK and globally, at the moment, with our third Prime Minister in as many months, the ongoing cost of living crisis and the war in Ukraine. It is easy to feel as though the last few years have taken their toll. However, it is my hope that with initiatives to improve maternity care, we can continue to fight for equality, compassion and the very best outcomes for families in the UK, and make our own contribution to shining a light in these difficult times.