Thread by @ShaunLintern

BREAKING: The report into poor maternity care at #EastKent has been published and says it found a clear pattern of poor care leading to 45 baby deaths. Better care could have made a difference in 97 cases examined.

Read the report here: assets.publishing.service.gov.uk/government/upl…

"We have found that the Trust wrongly took comfort from the fact that the great majority of
births in East Kent ended with no damage to either mother or baby"

How often is that the stock phrase by NHS trusts in response to concerns? #EastKent

"The origins of the harm we have identified...lie in failures of teamworking, professionalism, compassion and listening" #EastKent

"We found gross failures of teamworking...a series of problems between the midwives, obstetricians, paediatricians and other professionals...Some staff have acted as if they were responsible for separate fiefdoms, cultivating a culture of tribalism" #EastKent

"We have found divisions among the midwives which at times included bullying to such an extent that the maternity services were not safe" #EastKent

"God only takes the babies that he wants to take"

There can be no place in the NHS for comments like this to a mother whose baby has just died. #EastKent

Diabetes? Meh not an issue for these midwives #eastkent

Safety investigations were often conducted narrowly and defensively...a junior obstetrician or midwife was often found who could be blamed #eastkent

#EastKemt "demonstrates the problems that occur when some consultants stubbornly refuse to change unacceptable behaviour"

No shortage of regulators at #EastKent but "the system as a whole failed to identify the shortcomings early enough and clearly enough to ensure real improvement followed."

.@NHSEngland was warned about poor maternity care at #EastKent as early as spring 2013 - these warnings got no traction.

This was a time when NHSE was not interested in safety. Simon Stevens hived it off to a separate body, despite the responsibilities being in legislation.

How maternity scandals are made. Tough questions for the @MidwivesRCM here. Is it a union or a professional body? Are midwives above patient safety?

#EastKent report says individual clinicians are not to blame: "We have concluded that accountability
lies with the successive trust boards & CEOs/Chairs. They had the info that there were serious failings, and they were in a position to act; but they ignored the warning signs"

The @gmcuk was unable to tackle poor consultant behaviour at #EastKent

"We have found, however, that the way in which “normal birth” was spoken about and set out in material for mothers created an expectation that it was an ideal that staff and women should strive to achieve." #Eastkent #normalbirth #maternitysafety

The scale of harm at #EastKent

Here are the main 4 recommendations made by the #EastKent inquiry to try and prevent similar failures happening again. I am afraid some of these leave me distinctly unimpressed. But Rec 1 and 4 seem best? What do you think twitter?