This week the Department of Health and Social Care has set out the Government’s response to the recommendations of the Independent Investigation into East Kent Maternity services. This short article sets out Patient Safety Learning’s initial reflections on this.
The investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust revealed a series of serious patient safety failings between 2009 and 2020, which resulted in avoidable harm to patients and deaths. In its report, published on the 19 October 2022, it stated that if nationally recognised standards had been followed, the outcome could have been different in 97 of the 202 cases reviewed.
The Government has now issued a policy paper formally responding to the report’s recommendations, which can be found here.
Commenting on this Helen Hughes, Chief Executive of Patient Safety Learning, said:
“The findings of the East Kent Maternity investigation echo problems we have seen highlighted in other inquiries and reviews into serious avoidable harm and preventable deaths in recent years. If we are to truly tackle these issues, we need to bridge the implementation gap that prevents recommendations from such inquiries being translated into improvements in patient safety.
All too often, recommendations are implemented inconsistently, with a lack of transparency and little monitoring or evaluation to assess their effectiveness in reducing avoidable harm. We await to see if the newly created national oversight group can help to create a more joined-up approach in maternity and neonatal care in this respect.
Many of the issues highlighted by the East Kent report are not simply specific to maternity: themes of organisational and regulatory leadership, failure to learn and act upon that learning; failure to set standards for behaviours and hold people to account within a just culture. These are systemic failures. Without a system-wide approach, such issues will continue to fall through this implementation gap, with avoidable harm inevitably reoccurring for years to come.
We will be looking in further detail at the Government’s response to this inquiry in the coming days and its implications for patient safety more broadly.”
