CEOs and chairs blamed for care failings which led to death of over 40 babies

Bill Kirkup’s inquiry into East Kent Hospitals University Foundation Trust found 45 of the 65 deaths of babies examined could have been prevented. It also concluded the overall outcome of 48 per cent of 202 cases investigated could have been different, if care had matched nationally recognised standards. 

It also warned that the unjustified belief that things “would get better” as a result of management changes still continued at the trust.

The report, published this morning, added that problems in the service were visible to senior managers and the board through a succession of reports, dating back to 2009. 

The report stated: “We have concluded that accountability lies with the successive trust boards and the successive chief executives and chairs. They had the information that there were serious failings, and they were in a position to act; but they ignored the warning signs and strenuously challenged repeated attempts to point out problems. This encouraged the belief that all was well, or at least near enough to be acceptable. They were wrong.”

Dr Kirkup said the issue of whether the board members involved in the scandal should still be working in the NHS was a matter for NHS England.

Stuart Bain, who served as chief executive until 2014, has retired. Chris Bown was interim chief executive for a period in 2015, he was interim CEO of London North West Healthcare NHS Trust until February this year. Matthew Kershaw, chief executive from early 2016 to late 2017, now runs Croydon Health Service Trust. Susan Acott, who was chief executive from 2017 until earlier this year, is not thought to be in a board position in the NHS. Current chief chief executive Tracey Fletcher was EKHT’s chief operating officer between 2008 and 2010.

Longstanding chair Nicholas Wells retired in 2015. He was followed briefly by Nikki Cole, and then former Imperial College Healthcare Trust Professor Stephen Smith, who held the positioon until 2021. Former NHS Confederation, King’s Fund and General Medical Council chief executive Niall Dickson is now the trust’s chair.

The inquiry report continued: “It is clear that concerns have arisen throughout the period since 2009 when the trust was constituted, and that numerous opportunities have been missed to rectify the situation that had developed.

“It is likely that the sooner this was tackled, the more straightforward it would have been, before problematic attitudes and behaviour, and dysfunctional teamworking, became embedded. Yet each of these opportunities was missed in one way or another, and the consequences continued.”

Over the 11-year period the review covered – 2009 until 2020 – it said those responsible for the services “too often provided clinical care which was suboptimal and led to significant harm, failed to listen to the families involved, and acted in ways which made the experience of families unacceptably and distressingly poor”. 

The report noted the trust was very active in producing “action plans” to address emerging problems, but added: “these plans and the way in which the trust board engaged with them masked the true scale and nature of the problems.

“Instead, the plans supported an imagined world where there were fewer problems, and where the plans associated with newly appointed staff were deemed to be sufficient despite the previous recurring pattern of failure. Individuals were lauded only to fall out of favour, sometimes quite quickly.

“The repeated turnover of staff at many levels, including chief executive, served to encourage this cycle; each time it was believed that this time things really would get better. Looking at cases to the end of 2020, we have not seen evidence to convince us that this cycle has ended.”

The report also detailed:

• Gross failings of teamwork, with “some staff [acting] as if they were responsible for separate fiefdoms, cultivating a culture of tribalism”;
• “Clear and repeated” failures to act professionally, including those midwives who were not part of a clique at one hospital being assigned to the highest risk women and challenged to achieve delivery without intervention –  a practice described as “downright dangerous”; and
• Poor responses after safety incidents, with defensiveness and blaming of junior staff. 

The inquiry also found many of the problems involving midwifery and obstetric staff were known to the board but not successfully addressed. 

Dr Kirkup, who also led the inquiry into maternity failings at University Hospitals of Morecambe Bay FT, said that he never expected to be reporting on a similar set of circumstances seven years later, adding:  “This can’t go on.”

In a statement, the trust’s new CEO Tracey Fletcher apologised to the families involved, adding the provider “must now learn from and act on this report”. 

She continued: “In the last few years we have worked hard to improve our services and have invested to increase the numbers of midwives and doctors, in staff training, and in listening to and acting on feedback from the people who receive our care.

“While we have made progress, we know there is more for us to do and we absolutely accept that. Now that we have received the report, we will read it in full and the board will use its recommendations to continue to make improvements so that we are providing the safe, high-quality care our patients expect and deserve.”

 Updated 17.00 19 October with mention of Chris Bown