Reading the signals – will it be different this time? 

Paul Whiteing

Paul Whiteing

By Paul Whiteing, Chief Executive, Action against Medical Accidents

August 2023



Just as Parliament went into recess, the Government published their very detailed response to Dr Bill Kirkup’s report “Reading the signals: maternity and neonatal services in East Kent”. Dr Kirkup’s report detailed the poor maternity care that over 200 families received at the trust between 2009 and 2020, which resulted in several examples of avoidable harm. 


Dr Kirkup made five inter-related and very thoughtful recommendations covering the following areas: 

  • Recommendation 1: To introduce valid maternity and neonatal outcome measures capable of identifying trends and outliers. 
  • Recommendation 2: Improvements to professional education to better embed compassionate care and ensure better compliance with professional behaviour. 
  • Recommendation 3: Improvements to teamworking in maternity and neonatal services, including improvements to junior doctor training in this regard. 
  • Recommendation 4: To bring forward a bill placing a duty on public bodies not to deny, deflect and conceal information from families and other bodies alongside consideration of trusts’ approach to reputational management and NHS England’s consideration of their approach to poorly performing trusts; and 
  • Recommendation 5: That East Kent accepts the reality of these findings, acknowledges the unnecessary harm caused and embarks on restorative processes to address the problems. 

Gaps in the Government Response

The Government spent 30 pages outlining their detailed and considered response. The Minister, Maria Caulfield MP, is to be congratulated, along with her Department and NHS England, on such a detailed response. 

But I spy some critical gaps in that response, which I hope will be addressed. 

First, the Minister says in her opening remarks, “I know everyone who joins the healthcare profession sets out to deliver safe and compassionate care…”.

No one disputes that, but it is also true that what shines through Dr Kirkup’s forensic report is the poor behaviours that emerged at this trust which contributed so much to the resulting harm to so many families. This goes to management and leadership and the need for managers to call out these behaviours early before they become normalised into rotten cultures.

Blaming the problem on frontline staff – something we at AvMA still see – is not good enough.

This issue has been a feature of so many inquiries and is the responsibility of everyone in leadership roles to address and be held to account for. Blaming the problem on frontline staff – something we at AvMA still see – is not good enough.

And it is concerning that the Government say “…” Dr Kirkup’s investigation…show that employers do not always feel equipped to take early action to tackle shortfalls in the behavioural standards of medical, midwives and other healthcare professionals.”

I am not clear what from this response will change things. However, it is the responsibility of managers and leaders to address poor behaviour promptly and effectively. They are paid to do that. 

The Need for Legislative Sanction: Emphasizing Absolute Candour

In respect of Recommendation 4, which is Dr Kirkup’s excellent attempt to use the threat of legislative sanction to underpin the need for absolute candour, the Government spend five pages saying what they are doing. But they do not commit to delivering this legislation Dr Kirkup recommends.

Instead, they link their response to the Hillsborough disaster and their response to that which they will publish “in due course”. And yet, at the same time, the Government freely admit “that some of those involved in East Kent did not adhere to the duty of candour”.

the Government freely admit “that some of those involved in East Kent did not adhere to the duty of candour”.

This is a shocking admission and begs the question, “And what are the consequences of that?” This cannot be the last word on the subject, and here I support the Parliamentary and Health Ombudsman, Rob Behrens, who recently called on the Government to review the use of the Duty of Candour across the NHS. 

Missed Opportunity

AvMA has proposed the deployment of independent senior advocates in the NHS to assist patients and their families in cases like those seen in East Kent.

In this report, the Government trumpets the roll-out of such a scheme but forgets to admit that the people are being employed directly as NHS staff and, as such, cannot ever be truly “independent” —such a missed opportunity which can still be addressed.  

Disappointing Next Steps

And finally, in what, as I say, is a very detailed response, it must be a disappointment to get to the very end only to find just eight lines of type under the heading “Next Steps”.

There are fine words of commitment here, but we deserve more by way of timescales and clarity as to a progress report about delivery against such important interlinked recommendations from Dr Kirkup and his very helpful and insightful report.