Agenda item

In attendance from EKHUFT for this item: Tracey Fletcher, Chief Executive Officer, Sarah Shingler, Chief Nursing and Midwifery Officer, Dr Rebecca Martin, Chief Medical Officer, Zoe Woodward, Consultant Obstetrician and Gynaecologist and Clinical Director for Women’s Health and Carol Drummond, Interim Director Midwifery.

1.    On behalf of the Committee, the Chair said his thoughts were with the families over the unimaginable heartache that was the result of avoidable and preventable failures at the Trust. The Trust had not been willing at first to accept those failures, but he hoped to hear that the system had changed significantly to address such concerns.

2.    Ms Fletcher said the Trust was deeply sorry for what had happened and fully accepted the themes and findings of the Kirkup report. Improvement work at the Trust had already begun, particularly around listening to families and governance processes, but there was much more to be done.

3.    In terms of staff changes, there was a real push to identify any issues at the time and not wait for a future review. Recruitment had taken place, including a new Head of Midwifery. The importance of customer care was highlighted.

4.    Locum doctors had to undertake 1 week’s mandatory training and would not run a ward independently unless a supervisor approved it. The Royal College of Nursing was overseeing the portfolio of locum doctors which was a positive step to secure professionalism.

5.    The importance of shared goals was discussed, along with how staff knew about them and understood expectations. These were important, but staffing pressures and the physical environment did have an impact on their deliverability.

6.    Ms Shingler spoke of leadership issues in the postnatal ward and how changes had been made with external candidates. 2-hourly rounds had also been in place for six weeks.

7.    The Trust were in contact with 28 out of the 202 families contacted as part of the Kirkup review. They were expecting that number to increase, and were open to working with each family taking into account individual expectations and wishes.

8.    There was a discussion about the temporary removal of Entonox at the maternity department in William Harvey Hospital. The Trust became aware of high levels of gas in the air that could be harmful to staff who work in the labour rooms for long periods and therefore took the decision to suspend its use until the issue could be fixed. Referring to a recent visit to the maternity unit at QEQM, the Chair questioned the funding available to improve the situation and offer piped Entonox at both hospital sites. Ms Shingler explained piped Entonox was used at William Harvey (it was not piped at QEQM) but that air ventilation improvements were needed. Ms Fletcher referenced the physical limitations on the sites and accepted capital improvements were needed but were on a list of Trust priorities that needed addressing with limited capital.

9.     A member asked each guest what their key priority for the Trust was, and responses ranged from improving culture and behaviours, to developing skills and creating a safe environment.

10.Asked why a patient would be turned away from one hospital and sent to another, Ms Drummond said there were two elements: 1) the maternity unit being at capacity and unable to safely take more patients, and 2) a woman who goes into labour early may need to go to William Harvey as QEQM can only accept patients who have passed a certain gestation point.

11. Setting out the Board’s responsibilities, Ms Fletcher explained they were accountable for enacting the themes identified in the Kirkup report. Change needed to be sustainable, and not create new initiatives. Numerous pillars were in place, and it was down to the Board to agree how to bring those pillars together and communicate them to staff and communities.

12.Since May 2022, women had been offered a follow-up call with a midwife to ask about their experiences of the quality of care received. Common themes were dealt with across the organisation. EKHUFT were the only Trust in Kent and Medway to offer this level of engagement, and they had been asked to talk about it at a regional leadership event. The response rate of 64% was pleasing though they aimed for 80%.

13.The Chair spoke of the future and the level of improvement needed. He referenced a letter he had written to the Secretary of State asking for a swift decision about the East Kent Transformation Programme which would lead of capital improvements. He highlighted the need for a second obstetric unit at QEQM. He asked the Trust to return to the Committee with an update on improvements made.

14.RESOLVED that the report be noted and the Trust return at an appropriate time.