East Kent Maternity Safety: Warning Signs Still Flash

Donna Ockenden’s Nottingham Maternity report, published on Wednesday last week, should make uncomfortable reading in East Kent. Not because Nottingham and East Kent are the same case. They’re not. But because the same warning words keep coming back: listening, triage, escalation, staffing, culture, governance, truth. Four years after Kirkup said East Kent had missed the signals, the Trust’s own 2026 board papers show fresh maternity warning lights.

There are some stories where the past refuses to stay in the past. East Kent maternity is one of them.

Four years ago, Dr Bill Kirkup’s Reading the signals report examined maternity services at the William Harvey Hospital in Ashford and the Queen Elizabeth The Queen Mother Hospital in Margate between 2009 and 2020. It found a “clear pattern”: suboptimal clinical care, significant harm, families not listened to, and experiences made “unacceptably and distressingly poor”. The panel said that if care had met nationally recognised standards, the outcome could have been different in 97 of 202 assessed cases, and in 45 of 65 baby deaths.

That’s the elephant in the NHS room.

Donna Ockenden’s long-awaited Nottingham review isn’t about East Kent. It’s about Nottingham University Hospitals NHS Trust. But the national lesson is hard to miss. Ockenden says her report shows what happens when “leadership, governance and culture” are not robust, when poor practice is not investigated, when learning isn’t built in, and when mothers and babies are failed at the most vulnerable point in their lives. She also says many of the themes are “not new” to those overseeing maternity care in England.

East Kent has heard that music before.

Kirkup warned in 2022 that it was too late to pretend East Kent was just another one-off disaster. Morecambe Bay had already happened. Shrewsbury and Telford had already happened. East Kent had happened. Nottingham was already in view. His warning was short enough to fit on a hospital noticeboard: “there will be more”.

Ockenden is the “more”.

That doesn’t mean East Kent is Nottingham. It doesn’t mean East Kent’s maternity service hasn’t improved. It has. The Care Quality Commission’s latest maternity assessments, published in May 2025, rated maternity at both WHH and QEQM as “Good” overall. Women responding to the CQC maternity survey also gave East Kent some strong scores for kindness, dignity, communication and partner involvement. That should be acknowledged honestly, because fair scrutiny doesn’t mean pretending improvement is not real.

But East Kent’s own board papers don’t support a cosy “job done” story.

In the June 2026 board pack, the Trust’s maternity performance section says the extended perinatal mortality rate had increased above the threshold of 5.42 per 1,000 births, standing at 5.50 in April. That measure includes stillbirths and neonatal deaths. The same paper says the stillbirth rate was above threshold at 4.64 in April, with three stillbirths in the month and 27 in the previous 12 months. It says the term stillbirth rate had also “significantly increased”, with 13 term stillbirths in the previous 12 months, and that a similar increase was seen at both WHH and QEQM.

Strip out the acronyms and the meaning is simple.

Babies died.

Stillbirth is the death of a baby before or during birth after 24 weeks of pregnancy. Neonatal death is the death of a baby shortly after birth. Perinatal mortality brings those measures together. So when a board paper says the extended perinatal rate is above threshold because stillbirths have risen, it’s not a sleepy dashboard wobble. It’s a maternity safety warning with families behind it.

That’s exactly where Kirkup and Ockenden meet. Kirkup said East Kent took false comfort from national statistics and failed to treat what women and families said as likely signal rather than noise. Ockenden says current maternity grading systems focus too heavily on outcomes and not enough on the quality of care processes, including listening, early recognition, escalation and teamwork. Different reports. Same lesson. The danger isn’t only the bad outcome. The danger is the system that explains it away before it has understood it.

The Trust’s papers say all eligible stillbirths and neonatal deaths are reviewed using the national Perinatal Mortality Review Tool. That’s important. PMRT is the structured national review process used to examine baby deaths and identify learning. But Kirkup’s whole warning was that an organisation can have review processes, committees and action plans, and still fail if the challenge is weak, the assurance is too soft, or the difficult truth gets diluted on the way up to the board.

This is where today’s Ockenden report makes the East Kent papers feel less local and much more urgent.

Ockenden found long-standing weaknesses in Nottingham’s antenatal care, including variation in risk assessment, surveillance, documentation, communication and escalation. She also identified triage as a weak link, with poor telephone risk assessment, missing documentation and a culture, over the review period, of discouraging women from attending in person. Kirkup had already found in East Kent that telephone advice telling women to stay at home was dangerous when women also reported other problems, including altered baby movements.

Now look at East Kent’s current papers.

The June board pack says triage standardisation work is under way after Maternity and Newborn Safety Investigations concerns. It says this is being supported by audits, a triage dashboard, weekly metric reviews, and preparations for full BSOTS alignment when the K2 electronic maternity system arrives in early 2027. BSOTS means the Birmingham Symptom-specific Obstetric Triage System: a structured way of assessing maternity risk so women are not handled by guesswork, habit or whoever happens to take the call.

That sentence, unlike the breeze, should not drift past anyone.

If triage is the front door of maternity risk, East Kent’s own papers say work to standardise that front door is still under way 4 years after national safety investigation concerns. Full alignment is linked to a digital system expected in early 2027. So the public question is obvious: what’s controlling the risk today, before the new system arrives?

There’s a physical version of the same problem. The June pack lists delays in relocating the WHH Suite so the Trust can reconfigure WHH triage space. It also lists the closure of a remaining CQC “must do” about the maternity environment. That’s not just bricks, paint and NHS estate-speak. CQC’s WHH maternity assessment said the estate didn’t effectively meet the needs of women and families, didn’t follow national guidance, and that restricted space and facilities compromised women’s experience and dignity.

In maternity, space is safety.

A cramped triage area isn’t just inconvenient. It can affect privacy, dignity, assessment, staffing, observation and speed. CQC said WHH maternity was “Good” overall, and that is a real improvement. But it also rated “Safe” as “Requires improvement”, and said the 1977-built estate needed significant funding to be fit for purpose. That’s the uncomfortable double truth: better, but not settled.

QEQM tells a similar story. CQC rated maternity there “Good” overall and said women and families were positive about warmth, kindness and effective care. But “Safe” was also “Requires improvement”. For any hospital, that matters. For East Kent, after Kirkup, it matters twice.

The CQC maternity survey gives the Trust something solid to point to. East Kent scored 8.7 out of 10 for labour and birth, 8.5 for staff caring for women, and 8.1 for care in hospital after birth. Partner involvement during labour and birth scored 9.5. Respect and dignity scored 9.3. Kindness and compassion during labour and birth scored 9.1. After birth, partner length of stay scored 9.6 and kind and understanding care scored 8.9, with CQC rating those two post-birth questions “somewhat better than expected”.

Good.

But not enough.

The lower scores are where the old reports start whispering. Opportunity to ask questions about labour and birth scored 7.0. Not being left alone by midwives or doctors when worried scored 7.8. Pain management during labour and birth scored 7.7. Staff being aware of medical history scored 8.0. Concerns being taken seriously once raised scored 8.1. CQC rated those “about the same” as most trusts, not worse. But after Kirkup, “about the same” cannot be the ambition when the subject is women being heard, watched and believed.

A mother being able to ask questions is not customer service.

It’s safety.

A woman not being left alone when she’s worried is not a courtesy. It’s safety. Staff knowing her medical history isn’t admin. It’s safety. Taking concerns seriously isn’t kindness layered on top of clinical care. It’s clinical care. Kirkup said East Kent families were too often not listened to. Ockenden says Nottingham families repeatedly described feeling unheard, inadequately informed and unsupported when expressing anxiety. That’s why survey scores in those areas deserve a harder stare.

The board papers contain positives. The June maternity assurance report says March patient feedback through “Your Voice is Heard” was 96.9% positive about antenatal care, 96.8% positive about intrapartum care, 90% positive about postnatal care and 95.2% positive about neonatal care. It says positive themes included care by staff, care during emergencies and theatre, communication and information.

Then the same paragraph turns.

Negative themes included communication, waiting times to be seen in triage and postnatal care. Communication. Triage. Postnatal care. Three ordinary phrases. Three places where maternity scandals can begin, deepen or be compounded.

Training is another flashing light.

The June pack says PROMPT compliance was 94.7% overall. PROMPT is practical emergency maternity training, the rehearsal for when childbirth suddenly becomes dangerous. Fetal monitoring compliance remained above the Saving Babies’ Lives stretch target of at least 95%, and Newborn Life Support compliance was 93%. Those are important positives.

But the same section says training space remains an area of focus, the Newborn and Infant Physical Examination medical lead has stepped down with no replacement, and NIPE compliance for all parts of training is “minimal”. NIPE is the newborn baby check. Staff who have not completed the training are not permitted to do those examinations, which the paper says reduces capacity.

Again, the seesaw.

Better numbers in one place. Basic fragility in another.

Ockenden’s Nottingham report found that failures in training, management, oversight and escalation sat inside a wider culture of staffing and administrative pressure. Kirkup found that East Kent’s historic failures were not explained by one clinical error, but by failures of teamworking, professionalism, compassion and listening. The Trust’s current papers do not prove a repeat of those failures. But they show the same fault-lines are exactly where the Trust still has to keep proving itself.

There’s also the matter of incidents.

The June Integrated Performance Report says moderate to severe maternity incidents had remained elevated for a sustained period, highlighting ongoing patient safety risks and the need for continued improvement focus. That’s the board paper’s wording, not ours. It’s not dramatic. It’s worse than dramatic. It’s official.

The Maternity and Neonatal Assurance Board report also escalated four Maternity and Newborn Safety Investigations cases referred and accepted during Quarter 4, HIE cases and rates, Freedom to Speak Up themes, maternity staffing, a review of staffing models with rising caesarean rates, and Safety Champion feedback on staffing levels and the process for releasing bank shifts. HIE means hypoxic-ischaemic encephalopathy, a brain injury caused when a newborn baby doesn’t get enough oxygen and blood around birth.

Those are not decorative headings.

They’re the plumbing of safety.

And because this is East Kent, governance matters just as much as the clinical detail. Kirkup heard evidence of “really awful reporting to the board”, with “no challenge or testing at executive level”, and said nobody really knew the truth about a problem or rather didn’t want to hear it. He also recorded concerns that governance was not a golden thread running through maternity services and that issues could not always be escalated upwards.

The current papers show a much more developed assurance machine. There’s a Maternity and Neonatal Assurance Board. There are PQOM reports, MOSS alerts, CNST safety actions, external oversight, improvement programmes, training dashboards, review tools and board escalations. That’s progress. But Kirkup and Ockenden both warn, in different ways, that process doesn’t equal safety unless it changes what happens to women, babies, families and staff.

That’s why Ockenden’s Nottingham report is so dangerous for any trust hoping to hide behind “lessons learned” language. Nottingham had previous reviews. Its board had seen reports. The Ockenden report says the challenges and weaknesses were known by service and corporate leaders as far back as 2015, and that if earlier reports had been acted on, many family experiences and outcomes would have been different. East Kent knows exactly how that reads.

The national Government knows it too. In September 2025, East Kent Hospitals Foundation NHS Trust was named as one of 14 trusts in Baroness Valerie Amos’s national maternity investigation. The Government said the investigation followed repeated reviews showing similar patterns: women’s voices ignored, safety concerns overlooked and poor leadership creating toxic cultures. It also said East Kent was one of three trusts chosen where previous investigations had taken place, so learning from those earlier reviews could be incorporated.

So no, East Kent isn’t just a historic case study.

It’s still part of the national maternity story.

The Trust can fairly say it has improved. CQC says maternity at WHH and QEQM is now Good overall. The CQC survey gives several strong scores. The board papers show high patient satisfaction in places, better training compliance in places, MOSS monitoring, external review processes, Saving Babies’ Lives work, and structured oversight. Any honest article has to include that, because the truth is not helped by pretending the Trust is frozen in 2022.

But improvement isn’t the same as safety settled.

East Kent’s own 2026 papers show the extended perinatal mortality rate above threshold, stillbirth above threshold, term stillbirth significantly increased, a level 2 MOSS signal at QEQM, moderate to severe incidents elevated for a sustained period, triage standardisation still under way after MNSI concerns, WHH triage reconfiguration delayed, antenatal education delayed, unresolved Ockenden actions, NIPE training minimal, a NIPE medical lead gap, limited training-space capacity, staffing concerns and Freedom to Speak Up themes. That’s not a vibe. It’s the paperwork.

This is the story now.

East Kent was told to read the signals. Ockenden has just shown the country what happens when maternity warning signs become familiar wallpaper. East Kent’s latest board papers show new warning signs in the same landscape: deaths, data, triage, training, staffing, listening, governance and culture. The issue isn’t whether the Trust can produce reassurance. It can. The issue is whether the Board, NHS England, Kent and Medway ICB, CQC, governors and MPs are testing that reassurance hard enough.

Because families shouldn’t have to become investigators.

They shouldn’t have to learn acronyms after grief. They shouldn’t have to understand MOSS, PMRT, PQOM, MNSI, BSOTS, NIPE, HIE and CNST just to know whether a hospital is listening properly. They should be able to trust that when the warning lights flash, someone with power sees them, understands them, acts on them and tells the public plainly what is being done.

Kirkup called his report Reading the signals.

Four years later, the question for East Kent is painfully simple.

Who is reading them now?

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