London, 19th October 2022: Once again, an inquiry has found that maternity services have failed to deliver care safely, which has led to the deaths of dozens of babies and poor care for dozens more babies and their families. Once again, an inquiry finds that care was unkind and uncompassionate, families ignored, and when asked to explain why babies had died, the service blamed the families and hid the truth.

Once again, it has been the families of those children who have had to fight to get to the truth. I applaud their courage and extend my heartfelt sympathies to all the families who have been harmed by such negligent care.


There is so much in this report that is appalling that it’s difficult to choose the most shocking behaviour. There is plenty to go around including gross failures in teamworking, lack of professionalism and compassion, and failing to listening to patients. This latter problem is one we have seen in all recent reports.

Beyond the failure to provide safe and compassionate care, the report highlights a profoundly worrying failure to be honest with families about what happened. As the report’s author, Dr Bill Kirkup, asks in the report: "How much more difficult must it be if the death need not have happened?... If the circumstances of your baby’s death were not examined openly and honestly, leaving the inevitability of future recurrence hanging in the air?"

This is shocking. I can’t imagine how hard it is to raise a complaint or a concern, to then have to doggedly pursue it to get answers. It is the responsibility of the organisation to ensure honest and thorough investigations, working in partnership with patients and their families. Or it is for the regulators, the professional bodies and the leadership of the NHS to hold units and hospitals to account. But the Kirkup report found the system as a whole failed to identify the shortcomings early enough and clearly enough to ensure that real improvement followed.


As a patient organisation, we find it insufferable that we are, once again, commenting on issues that have been raised so many times. As Dr Bill Kirkup says in the report, Reading the signals: Maternity and neonatal services in East Kent: “It is too late to pretend that this is just another one-off, isolated failure, a freak event that ‘will never happen again’.”

Surely, we cannot tolerate a situation in which each maternity service has to be investigated in order to learn how to provide compassionate care? Dr Kirkup suggests there needs to be a mechanism that identifies when a maternity unit’s standards are not adequate, but recognises change is hard.

The report identifies that cultures within services can become embedded and are, therefore, difficult to change, and says that until issues such as poor team working and uncompassionate care are resolved, issues seen in East Kent, in Shrewsbury and Telford, and in Morecombe Bay, will repeat. This cannot be allowed to happen and, while we know another report is coming into maternity services in Nottingham, we hope the Kirkup recommendations will be acted on. These are:

  • Monitoring safety performance: every trust must have a mechanism to monitor the safety of its maternity and neonatal services, in real time and the NHS must monitor the safety performance of every trust, and act immediately on any signals that suggest something is wrong.
  • Standards of clinical behaviour: the need for staff to behave professionally and to show empathy. Part of a professional approach is to explain what is happening, honestly and openly, and to listen to families.
  • Flawed teamworking: the report makes several suggestions that should be adopted in how teams train and staff are educated, and we support the idea that a better concept of teamwork for maternity services is needed.
  • Organisational behaviour: Leadership is critical to setting the appropriate culture in any part of the NHS. In East Kent, reputation was management was prioritised over being honest with families, and this isn’t the only trust where this has happened. The report says: “It seems that NHS regulation alone is unable to curtail the denial, deflection and concealment that all too often become subsequently clear, and more stringent measures are overdue.” We look forward to being asked to contribute to what these new measures could be.

Too many

This is the second maternity services inquiry I’ve read this year; that’s two too many. Parents-to-be should feel safe throughout a pregnancy and during labour and delivery. They should be cared for with kindness and compassion, by well trained professionals who themselves are supported and work in a safe environment. Patients and their families should be listened to and, if something goes, wrong the hospital should care about the truth and worry less about reputation management.

Rachel Power

You may also be interested in our comments on the Care Quality Commission's State of Care report, also published this week.

Picture credit samuel Lee from Pixabay