The Kirkup report 2015 – where are we now?
March 25, 2024
You’re having a baby! The joy and trepidation of bringing a child into this world is, some might say, like nothing else. But with all the reports of scandal, failing maternity units and poor care, where do you go? Some report that midwives don’t listen and there are midwifery reports of a lack of support and direction. Are they, the staff at the coal face, causing the problem or is the problem a more fundamental one, is the issue one of governance?
Cohesion, direction and guidance should come from the top. Wanting to understand how the NHS has responded to review and recommendations, we started in Morecambe Bay. In 2015 Bill Kirkup undertook an independent investigation into the management, delivery and outcomes of care provided by the maternity and neonatal services at the University Hospitals of Morecambe Bay NHS Foundation Trust from January 2004 to June 2013. The investigation found ‘a distressing chain of events that began with serious failures of critical care in the maternity unit at Furness General Hospital’ the result being avoidable harm to mothers and babies including tragic and unnecessary deaths…this report includes detailed and damning criticisms of the maternity unit, the Trust and the regulatory and supervisory system.’
The Kirkup report gave us a level from where we could compare CQC investigations and reports that were carried out in the years following to see how change had been implemented and whether anything had changed. The CQC report from the 3rd December 2015 recommended that at one of the hospitals they should ‘ensure there are clear lines of responsibility and accountability at ward manager and matron level within maternity so that staff feel supported and barriers to communication and change are removed’. By the 9th February 2017 the CQC said that the Trust should ‘continue to monitor the cultural assessment survey for obstetrics and gynaecology and improve values around organisational culture.’
On the 19th March 2020 the CQC set out that the ‘trust should consider increasing the visibility of senior leaders across maternity and children and young person services’ and that ’the trust must ensure all risks are assessed, monitored and actions taken to mitigate them are effective and timely’. The trust were required to ensure that systems to collect and analyse data are effective and that validated data was easily accessible to staff to allow them to understand performance, make decisions and improvements.
By 2021, 6 years on from the Kirkup report, the CQC said ‘the service should work to engage the workforce and increase visibility of the executive team’ and ‘the service should ensure that recommendations from external incident investigations are fully considered and appropriate, robust action plans put in place’. The report continued ‘The trust must ensure they establish and operate effective governance processes and systems, with robust action plans to monitor and improve the safety and quality of services and mitigate risks to women and families using the service’ and ‘the trust must ensure they establish and operate effective governance processes and systems, with robust action plans to monitor and improve the safety and quality of services and mitigate risks to women and families using the service’. Finally in 2021 ‘the service must continue to develop a vision and strategy through engagement with staff, focused on sustainability and aligned to local plans within the wider health economy.’
The most recent report completed in 2023 identified that ‘the service should continue to develop a long term vision and strategy through engagement with staff, focused on sustainability and aligned to local plans within the wider health economy.’ Other basic issues such as ‘the trust must ensure that mandatory training completion rates are in line with trust targets’ and ‘the service must ensure that there is a clear protocol for identifying women for prioritisation of induction of labour and that it is recorded in the care records’ were highlighted.
It must be recognised that one of the difficulties in using these reports to understand whether anything has actually changed is that they are compiled by different people and don’t have a truly consistent approach that enables easy comparison. But it does seem that some of the same fundamental issues identified in 2015 have not been addressed, leaving unanswered questions moving forward.
