Agenda item

In attendance: Liz Shutler (Deputy Chief Executive), Dr Paul Stevens (Medical Director), Dr Ciaran Crowe (Consultant Obstetrician), Dr Abigail Price (Consultant Paediatrician) and Hannah Horne (Deputy Head of Midwifery) from East Kent Hospitals University Foundation Trust.

1.    The Chair welcomed the guests to the meeting and invited them to introduce themselves.

2.    Ms Shutler began by saying that in 2015 the Trust recognised that it needed to improve care under its maternity services. They commissioned the Royal College of Obstetricians and Gynaecologists to review the service and following that a number of improvements were put in place. However, the Trust recognised that those improvements were not put into place quick enough or at the scale required.

3.    Around 7,000 babies were born under the Trust’s care in any one year and Ms Shutler asserted that one preventable death was one too many. The Trust recognised it had not always provided the standard of care it should have for every woman and baby, and Ms Shutler wholeheartedly apologised on behalf of the Trust to the families who should have received a different experience whilst in their care.

4.    The Trust fully accepted the coroner’s conclusions and recommendations from the January 2020 inquest. To address those recommendations the Trust had established an externally chaired Board (a sub-committee of the main Board) which in turn had seven task and finish groups each with its own area of focus.

5.    The Minister for Patient Safety had also announced an independent review being led by Dr Bill Kirkup. The Trust were committed to participating in that review and taking on board any recommendations.

6.    Mr Inett explained that Healthwatch had attended one of the review meetings and would continue to be involved. He said the Trust appeared to be clear on the action required from the Royal College report and the coroner’s recommendations. He did not feel the Trust were sidestepping the issues or trying to come up with excuses. He also pointed out that some actions were required by the Trust as a whole, not just the maternity services.

7.    A Member asked why things had gone so wrong despite there being a Royal College review in 2015. Dr Stevens explained that themes from that report had been repeated in subsequent reports which suggested any changes that were made failed to be embedded. The seven task and finish groups would be reviewing all the recommendations in a bid to understand where actions had not been strong enough.

8.    Asked how East Kent residents could be assured that the Trust’s Board was adequately monitoring the implementation of best practice, when they failed to do so in 2015, Ms Shutler explained that the chair of the new Board was independent in order to provide external opinion as well as assurance. The seven workstreams were overseen by clinicians which Dr Price felt demonstrated a real shift. Ms Shutler also felt it was important that the Trust accepted the additional clinical support on offer. Dr Stevens also pointed out that each of those present was an East Kent resident and therefore had a vested interest in making the services the best they could be. Dr Crowe felt, as a relatively new employee of the Trust, that the employer was recruiting different skillsets in order to build their workforce and that they were being open about the challenges being faced.

9.    A Member questioned why QEQM did not use the workforce planning system Birthrate Plus. Ms Horne responded that a tabletop exercise of the tool was undertaken in 2018 and it was decided it was not as sensitive as they would like for East Kent. Instead, they had appointed an external senior midwife who used the Birthrate Plus methodology.

10. A Member asked for a staffing update on the appointment of Speak Up Guardians and the Duty of Candour. Dr Stevens explained that three Speak Up Guardians had been formally appointed as well as a number of champions on each site, and their feedback would feed directly to the Director of HR. For the Duty of Candour, which all Trusts as well as the CQC were trying to drive forward, Dr Stevens explained that women and children were the core care group in terms of this and he understood that the service was completely up to date with initial letters sent to that cohort.

11. In response to a question about any public communications regarding where families could go for advice, Ms Shutler said that a helpline had been set up and publicised but the take up was low. Instead, she felt the most effective method for communication was between a woman and her lead midwife. They were encouraging women to contact the service directly and those calls would be triaged by a midwife.

12. In terms of timescales, Ms Shutler explained that no reorganisation would take place in the next 12-18 months and it would likely be 4-5 years until changes were implemented after consultation and any capital investment secured. However, Ms Shutler also recognised that the Trust didn’t move quickly enough in 2015 and that whilst a number of reviews were underway, they would not be waiting for the recommendations before implementing necessary changes.

13. Dr Crowe acknowledged that there were lots of things to be done, and they were having to be prioritised. Examples of actions that had been, or were being, taken included:

a.    remote foetal monitoring (where consultants could monitor a foetus from any location).

b.    further investment in training and development for both technical and non-technical skills;

c.    implementing controls to ensure increased consultant presence on the wards;

d.    appointment of three specialist midwives (one specialising in the Better Births agenda and two in foetal wellbeing);

e.    a piece of work to scope out continuing care and what that means for women and families in East Kent;

f.     Out of hour safety huddles to ensure ward leads had a helicopter view of the service at that time;

g.    investing in and expanding the Getting it Right First Time (GIRFT) programme; and

h.    the Chief Nurse holding “floor to board” meetings to gather intelligence and ensure staff feel listened to.

14. In terms of measuring service satisfaction, Ms Horne explained that all women were offered the “Friends and Family” test in order to provide feedback, as well as the “birth after thought” service. Feedback was triangulated and lessons learnt shared – both positive and negative. Dr Crowe added that Healthwatch sat on the oversight committee, as does the MVP Chair. It was important that the woman and family voice be part of every decision the Trust made.

15. A Member asked if a midwife sat on the Trust’s Board of Directors. Ms Shutler responded that nursing and midwifery representatives were on the Board as well as relevant sub-committees. The Director of Nursing was also an ex-midwife.

16.  The Chair thanked the guests for attending, and on behalf of the Committee he offered his deepest sympathies to the families affected. He summarised the three key pieces of work that HOSC would want to receive updates on, and what the timescales were:

a.    Healthcare Safety Investigation Brach (HSIB) which looked into certain categories of incidents in maternity units across the country. The Trust received quarterly reports and met with HSIB to review the findings and themes.

b.    NHS England independent review led by Dr Bill Kirkup. The timescales were unclear at that point in time.

c.    The Trust’s sub-committee with its seven workstreams. The Trust’s Chief Executive had set an expectation that initial conclusions would be available by the end of April.

17. RESOLVED that the report be noted and that the Trust be requested to provide an update at the appropriate time.