Our response to the Reading the Signals report

Transforming our Trust

On 19 October 2022, the Independent Investigation published its report into our maternity and new-born services, Reading the signals.

The report describes the harm and suffering experienced by women, babies and their families, in our care between 2009 and 2020. We recognise that families came to us expecting that we would care for them safely, and we failed them. We unreservedly apologise for these unacceptable failings.

On 21 October 2022, the Trust Board formally accepted the report in full and committed to addressing the four key areas for action in the report:

  • Monitoring safe performance

  • Standards of clinical behaviour

  • Flawed team working

  • Organisational behaviour

  • And; a recommendation specifically for the Trust to embark on a restorative process addressing the problems identified in partnership with families, publicly and with external input.

We have developed five programmes of work we have called our Pillars of Change. They link to the areas for action in the independent investigation report and to our values: that people should feel cared for, safe, respected and confident that we will make a difference.

The Pillars of Change set out the practical steps we have already begun to put into place and include the further work to be delivered over the next three years.

Some of this work can be implemented quickly, but some outcomes may take longer to achieve. Sustained culture change takes time.

We will set out key performance indicators to measure the effectiveness of the changes over the next three years, which will include achievable short term, medium term and three-year goals

In addition we are publishing an open letter to all residents of East Kent responding to the Investigation and setting out what we intend to do to address the concerns it has raised.

We will establish a comprehensive culture change programme involving every member of staff drawing on external advice and engaging patients and their relatives in its design and development.

We are also setting up a Reading the Signals Oversight Group. This forum will include representatives from patients and families as well as our Council of Governors, and will provide oversight of the programme, making sure there is engagement with those who use our services and that steps are taken to address the issues identified in the report. The group will meet in public and report directly to the Board of Directors. 

The Board will be responsible for overseeing this major transformation programme with day-to-day responsibility for delivery and monitoring progress taken forward by our Clinical Executive Management Group. Specific improvements in maternity and neonatology services will continue to be overseen by the Maternity and Neonatal Assurance Group, again reporting to Trust Board.

Introduction to the Pillars of Change

Pillar one: Reducing Harm and Safe Service Delivery

This relates to our value that ensures people feel safe, reassured and involved.

Where we want to get to by 2025

  • Effective systems and processes for responding to patient safety incidents are in place and learning and we will have embedded a patient safety culture so that we learn when things go wrong and we eliminate recurrent themes occurring

  • We will involve patients and families in investigations and ensure all their questions are answered

  • We will continuously seek opportunities to improve the physical environment for staff and patients.

Building our foundations (Dec 2022 – May 2023)

  • We will eliminate the backlog of SI investigations and will be fully compliant against agreed timelines for all new reported incidents in order to give patients and families answers in a timely way

  • We will introduce the new complaints process to ensure transparency and candour in our responses

  • We will commence the pilot ‘Calls for concern’ (Ryan’s Rule) to support adult patients, their families and carers, to raise concerns if a patient's health condition is getting worse or not improving as well as expected

  • We will refocus our Quality Improvement programme on We Care for Winter.

 Developing and evaluating (6-36 months)

  • We will implement the national Patient Safety Incident Response Framework (PSIRF) across the Trust, to develop and maintain effective systems and processes for responding to incidents, learning and improving safety

  • We will transform the approach to learning from complaints and incidents

  • We will evaluate and review the approach and focus of our Quality Improvement programme and roll out a revised programme across the Trust

  • We will develop our digital strategy with clinicians

  • We will carry out planned improvements to the environment in our maternity and neonatal units

  • We will evaluate the effectiveness of Calls for concern and roll out Trust-wide.

Examples of work we are building on

In 2021 we strengthened the quality of investigations and learning from incidents, including how we involve families. This included introducing a rapid review process to review potential serious incidents and ensure immediate safety actions have been taken. We now ask external clinical experts to undertake investigations and be part of case reviews. 

Pillar two: Care and Compassion

This relates to our value that ensures people feel cared for as individuals.

Where we want to get to by 2025

  • We will treat each other with care and compassion and work in teams that value and respect each other

  • Our teams will work together in a way that delivers better outcomes for patients.

Building our foundations (Dec 2022 – May 2023)

  • We will pilot ‘Civility Saves Lives’ in maternity, a programme to eliminate rudeness and incivility, which has been shown to have a positive impact on patient care

  • We will engage with staff in reviewing and renewing the Trust’s values

  • Establish a programme of engagement and listening with all Maternity staff

  • We will introduce a simple tool to assist staff to challenge poor behaviours

  • We will share and actively engage on the ‘Importance of Caring’ video which focusses on care and compassion for patients

  • We will implement the Inclusion and Respect Charter which sets out the behaviours we should expect from ourselves and others

  • We will reinforce our Internal Professional Standards, the standards of clinical care patients can expect, and build into work contracts, co-produced with our staff.

Developing and evaluating (6-36 months)

  • We will Implement ‘Civility Saves Lives’ in maternity and consider roll out across the Trust according to local feedback

  • We will review the Trust’s Values with staff, patients and public

  • We will develop a new Trust-wide behavioural code

  • We will review the recruitment process to test care and compassion beyond technical competence, designing this with patients

  • We will review the Freedom to Speak up Guardian Service and make sure we import best practice from other Trusts with the aim of becoming a leading Trust in national assessments.

Examples of work we are building on

In March 2022 we appointed a full-time Freedom to Speak Up Guardian for maternity, dedicated to listening to and supporting staff to raise concerns. There are two lead-consultant “safety champions” in Women’s Health and Neonatology and Lead Professional Midwifery Advocates.

Our Maternity and Neonatal Safety Champions include the Chief Nursing and Midwifery Officer, Interim Director of Midwifery, Non-Executive Director Maternity Champion and two lead consultants in women’s health and neonatology.

Pillar three: Engagement, Listening and Leadership

This relates to our value that ensures people feel teamwork, trust and respect sit at the heart of everything we do.

Where we want to get to by 2025

  • We have effective, embedded ways of listening to and involving staff

  • We are an employer of choice with high retention, low vacancies and improved staff satisfaction

  • We are a diverse and inclusive employer.

Building our foundations (Dec 2022 – May 2023)

  • We will revise our Trust-wide Communications and Engagement Strategy and deliver a communications and engagement plan consistently to reinforce the messages from Reading the signals

  • We will continue the Cultural and Leadership Programme, focussed on maternity, and review its effectiveness

  • We will develop our Leadership Framework

  • We will start the leadership programme to support the development of our team leaders, first-line and middle managers

  • We will introduce a mandatory Team Brief to help leaders communicate with their teams

  • We will establish a doctors in training group

  • We will engage all students on placement in our transformation programme seeking their views and feeding back actions take.

Developing and evaluating (6-36 months)

  • We will roll out a formal engagement and listening programme which will involve every member of staff working for the Trust and its subsidiaries

  • We will roll out the Cultural and Leadership Programme across the Trust

  • We will embed the Just Culture approach, aimed at supporting early resolution and learning from mistakes, and reducing formal disciplinary action where appropriate

  • We will develop and adopt the new Behavioural Code

  • We will establish an East Kent conversation so that every member of staff is consulted and involved as the transformation programme develops

  • We will engage all of those appointed to leadership posts within the new organisational structure in Leadership Development

  • We will establish Staff forums to give staff a greater voice and involvement

  • We will make sure that every member of staff given managerial or leadership responsibility is given ongoing support and training to be effective in their role

  • Our national staff survey results will improve year by year and we will set specific metrics to measure progress.

Examples of work we are building on

In 2021 we introduced a culture and leadership programme aimed at building relationships and multi-disciplinary team work, across our different hospitals and between maternity and neonatal services. It includes vision and values workshops, staff drop-in sessions, a leadership development programme as well as opportunities for teams to learn together.

Pillar four: Organisational Governance Development

This relates to our value that ensures people feel confident we are making a difference.

Where we want to get to by 2025

  • We have an embedded organisational structure with effective leadership open to challenge

  • We have effective governance processes from ward to Board

  • Partnership working is embedded and effective.

Building our foundations (Dec 2022 – May 2023)

  • We will continue oversight of the Maternity Improvement Programme through the Maternity and Neonatal Assurance group

  • We will revise and consult on the new organisational structure of the Trust

  • We will achieve compliance in Duty of Candour. Duty of Candour compels every health and care professional to be open and honest with patients when something goes wrong

  • We will commission an external review of the effectiveness of our Board

Developing and evaluating (6-36 months)

  • We will bring in external validation of the progress of improvement in maternity services, after 12 months

  • We will evaluate the effectiveness of the organisation restructure and associated governance arrangements

  • We will review and adapt how we work with other stakeholders, including the East Kent Health and Care Partnership, NHS Kent and Medway, NHS England’s regional office, the Care Quality Commission and our unions

  • We will complete a Board development programme based on the findings of the diagnostic.

Examples of work we are building on

In September 2021 we established the Maternity and Neonatal Assurance group, chaired by the Chief Nursing and Midwifery Officer and attended by the non-executive director maternity champion (a senior clinician). The group reports monthly to the Quality and Safety Committee and directly to the Trust Board quarterly. It provides specific oversight of maternity and neonatal services, including training compliance, the monthly maternity dashboard which has 85 key performance indicators, maternity improvement plan, progress against CNST, Ockenden and CQC actions.

Pillar five: Patient, Family and Community Voices

This relates to all of our values: people feel cared for, safe, respected and confident we are making a difference.

Where we want to get to by 2025

  • Patients feel listened to, involved and their concerns acted upon

  • We are honest and transparent in communicating with patients and admit when we get things wrong

  • Services are designed with patient.

Building our foundations (Dec 2022 – May 2023)

We will establish a Reading the Signals Oversight Group which will include representatives from patients and families as well as our Council of Governors. It will provide oversight of the programme, making sure there is engagement with those who use our services and that steps are taken to address the issues identified in the report. The group will meet in public and report directly to the Board of Directors. 

  • We will establish a programme of meetings with families

  • We will also implement a Trust-wide Patient Participation Group which is fully inclusive, with a patient representative as joint chair

  • We will expand Your Voice Is Heard in maternity to include a process for women to feel safe raising concerns, co-produced with families

  • We will establish and implement a process for case reviews for families where required

  • Lay chairs will be appointed to consultant appointment panels.

Developing and evaluating (6-36 months)

  • We will introduce Patient Participation Group representatives to board sub-committees

  • We will implement our Patient Voice and Involvement Strategy incorporating diversity and health inequalities as a priority

  • We will review the effectiveness of the Oversight Group and act on any findings.

Examples of work we are building on

We launched Your Voice is Heard in 2022, which means everyone is offered a follow-up call to discuss their experiences six weeks after giving birth, including their birthing partners, so that we can act on feedback and make changes. This work is supported by two patient experience midwives who were recruited specifically to improve the experience of families using our services. Specialist bereavement midwives are also working with families to improve how we care for families after a bereavement.