The publication of the Independent Investigation into East Kent Maternity Services report finds multiple failings in maternity care. These stark findings must be acted upon urgently.  

Today’s report on maternity and neonatal services in East Kent will be difficult reading for many, especially those parents grieving lost pregnancies and babies. 

The report clearly shows the devastating impact that failings at these services have had on families. It outlines multiple areas of poor care, highlighting a “clear pattern” of “sub-optimal” care which led to significant harm for families who were not listened to. 

This is the second major report to find serious failings in maternity services in England this year, following the Independent review into Maternity Services at the Shrewsbury and Telford Hospitals NHS Trust which was led by Donna Ockenden (now an ambassador for Sands).

Today’s report calls for a much more comprehensive, joined-up approach to improving maternity and neonatal services as a result of these reviews. 

Sadly, the report further found that had care been given to nationally recognised standards, the outcome of baby deaths could have been different in 45 out of 65 cases (69.2%). These tragedies must not be allowed to happen again.  

These findings and recommendations are not new. The 2015 Morecambe Bay Report, also led by Bill Kirkup, emphasised the need to be open and honest when things go wrong and to learn from incidents. 

This is such a difficult report to read, and my heart goes out to the parents and families who have faced so much pain and devastation and who have had to fight to be heard and for their stories to be told.

The report lays out clearly the areas that must be focused on if maternity safety is to improve, including establishing the early warning system which Sands has long been calling for and which will enable trusts that are failing to provide safe care to be identified and supported to improve. 

We know from the parents and families we support how important compassionate and kind care is; and we know that a culture of openness where human errors or systemic failings are acknowledged, and lessons are learned is vital if we are to stop these tragic events from recurring.

It is so sad that this report was ever needed, but action is now required to make sure that there never has to be another report into maternity services.  The Government must ensure that everyone acts together, as laid out in the recommendations, with all the necessary support and investment that is needed to make the UK the safest place in the world to have a baby.

Clea Harmer, Sands Chief Executive 

Key areas of action  

The report identifies four key areas of action for East Kent’s maternity services to take: Identifying poorly performing maternity services and neonatal units, giving care with compassion and kindness, teamworking with a common purpose, and responding to challenge with honesty.  

A culture of failings  

  Failures were identified in several areas at East Kent:  

• Poor teamworking  
• Lack of professionalism  
• Lack of compassion  
• Failure to listen to women and families 
• Not learning from safety incidents  
• A poor response from the Trust, including at a Trust Board level 
• Not identifying shortcomings early enough and clearly enough to ensure that real improvement followed  

Learning from the report  

Saving babies’ lives is a huge priority for Sands. We know, from experience of previous reports, that listening to parents’ voices is absolutely crucial when it comes to improving maternity care and ensuring that fewer babies die.  

This report has been carried out by prioritising families’ voices and their experiences in maternity care. East Kent must learn from the recommendations of this report if we are to create a system where fewer babies die and where families are prioritised.  

We are here for parents and families 

Today’s report on East Kent will undoubtably be painful for those families who were affected directly, and anyone else who has been affected by pregnancy loss or the death of a baby. We are here for anyone who needs us. If you, or anyone you know, have been affected by pregnancy loss or the death of a baby, we can offer support.