Maternity Services

Our response to the Reading the Signals report

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Reading the signals one year on

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In October 2022 Dr Bill Kirkup published the report of his independent investigation of maternity and neonatal services in East Kent.

On 19 October 2022 Dr Kirkup's report Reading the Signals was published by the Government.

The report from the independent investigation found that women, babies and their families had suffered significant harm because of poor care in our maternity and new-born services, between 2009 and 2020. The report also found that clinical care was not good enough and that we did not listen to women, their families and indeed at times, our own staff. The experience those families endured was unacceptably and distressingly poor.

The report highlighted care that repeatedly lacked kindness and compassion, both while families were in our care and afterwards, when families were coping with injuries and deaths. It also found at least eight opportunities where the Trust Board and other senior managers could and should have acted to tackle these problems effectively. This was simply not good enough.

The consequences were devastating. Of the 202 cases that agreed to be assessed by the panel, the outcome for babies, mothers and families could have been different in 97 cases, and the outcome could have been different in 45 of the 65 baby deaths, if the right standard of care had been given.

The Trust Board has apologised unreservedly for the pain and devastating loss endured by the families and for the failures of the Board to effectively act. These families came to us expecting that we would care for them safely and compassionately, but we failed to do that. We accept all that the report says, and we are determined to use the lessons within it to put things right.

We also want to apologise to those within our communities. We are aware of the anxiety that these failings will have caused among those who rely on our services. We are determined to make the necessary improvements and to make sure that in future we listen to patients, their families and staff when they raise concerns.

We are aware that saying sorry is not enough and that what is needed is meaningful action and real change. We are also clear that there is learning from the lessons in the report for every area of our organisation; these are not just confined to maternity.

That is why we are embarking on a fundamental transformation of the way we work. We are starting with a commitment to openness and honesty, so that whenever something goes wrong, everyone feels able to admit to and learn from our mistakes. Alongside this, everyone must feel able to raise concerns and to know they will be listened to, and their concerns acted upon.

The care we provide must be compassionate, not just sometimes but every time. We must do more to identify and address inequalities experienced both by patients and by staff.

In the last few years, we have worked hard to improve our services and have invested to increase the numbers of midwives and doctors, in staff training, and in listening to and acting on feedback from the people who receive our care. However, we know that we must do much more.

Right now, we are working on improving the way our teams work together so we can provide better, safer care; providing compassionate care across all our services; and making sure learning from our failings and mistakes is shared with all staff, so we can change the way we work so they do not happen again.

While we have made some progress, there have been previous efforts to tackle some of these problems and they have not been successful. We are determined to make sure that does not happen again.

We know there is a great deal more for us to do and we absolutely accept that.

On the following page we have set out the detail of our plans to improve the way we work:

Some of this work is new, some of it will build on work that has already begun. We will monitor this work closely and report on it and the progress we are making regularly and publicly.

We know the enormous pressures our hospitals are under, and we accept that changing how a large organisation operates will take time, but it is possible. We know too that if we are to succeed, we must learn from and involve patients and their families, and work in partnership with them to develop and deliver our response to the report.

If you would like to know more or to become involved, please do contact our Patient Voice and Involvement Team, or your Trust Governor.

If you have used our maternity or neonatology services, or any of the services we provide, and have questions or concerns about your care, please contact us via our PALS team, by phone on 01227 783145 or via email at

We are here to listen, to learn and to work with you and all our staff to bring about effective change.

Niall Dickson CBE, Chairman

Tracey Fletcher, Chief Executive