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Preventing recurring tragedies requires a highly coordinated system level response

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Dixon-Woods M. Learning from maternity service failures at East Kent Hospitals. The BMJ. 2022;379:02755

Why it matters

The 2022 report on maternity and neonatal services in East Kent Hospitals University NHS Foundation Trust is the latest in a series of horrifying investigations into failings in maternity care.

The outcomes in almost half (97) of the 202 cases reviewed would have been different if care had been provided to nationally agreed standards. Many of the deaths (45 of 64) and brain injuries (12 of 17) in babies could have been avoided, as could most of the maternal deaths and injuries (23 of 32).

The failings at East Kent have a lot in common with other high profile disasters in healthcare and elsewhere; they have their roots in a complex tangle of behaviours and systems.

However, a particular problem in this case was the failure to tackle unacceptable practices and behaviours, including unprofessional behaviour by some consultant obstetricians. The trust seems to have put off dealing with the problem, believing that it would probably lose at an employment tribunal if it took disciplinary action against consultants, although the evidence for this assumption is unclear

A second problem was that bullying, harassment, and discrimination were common. There were serious problems with the processes which should have tackled these issues, including human resources processes which seem to have been unfit for purpose.

At its most fundamental, what happened in East Kent was a system failure. The organisation’s weaknesses in tackling poor conduct, behaviour, and culture arose from problems in its leadership and management, especially human resources processes, but the wider context was also important. When the trust was clearly unable to handle the situation – or even properly recognise that it was happening – there was no effective mechanism to take over.

The discovery of the same failings in report after report shows lessons are not being learned. Preventing further tragedies requires a system-level, highly coordinated response that deals with the overlaps of different responsible bodies and the confusion around their authority and responsibilities. It will also need much improved management systems in NHS organisations, supported by clear standards and guidance, and evidence-based approaches to improvement that genuinely involve staff and patients.

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