The Kirkup Inquiry

The Kirkup Independent Inquiry into maternity services in East Kent was commissioned by Sir Simon Stevens, CEO of NHS England in April 2020 following Harry's inquest and reports commissioned by Health Minister Nadine Dorries MP from the CQC and HSIB.

The final report will be published on September 21st 2022 at 9am  At that time we will publish a link to the full report and make comments upon it here with comments and quotations.

In the meantime, Dr Bill Kirkup's report into the Morecombe Bay maternity scandal can be read here - Morecombe Bay

Here is just a snippet from the Morecombe Bay report which was published in 2015,  the same year that East Kent had their RCOG audit and 2 years before Harry was born. Please notice the last sentence. It is implausible that the Directors of East Kent were not aware of this report and its contents, yet the same things were happening in their Trust, and they knew it.

"This Report details a distressing chain of events that began with serious failures of clinical care in
the maternity unit at Furness General Hospital, part of what became the University Hospitals of
Morecambe Bay NHS Foundation Trust. The result was avoidable harm to mothers and babies,
including tragic and unnecessary deaths. What followed was a pattern of failure to recognise the
nature and severity of the problem, with, in some cases, denial that any problem existed, and a series
of missed opportunities to intervene that involved almost every level of the NHS. Had any of those
opportunities been taken, the sequence of failures of care and unnecessary deaths could have been
broken. As it is, they were still occurring after 2012, eight years after the initial warning event, and
over four years after the dysfunctional nature of the unit should have become obvious.

This Report includes detailed and damning criticisms of the maternity unit, the Trust and the regulatory
and supervisory system. In view of the progress that is now undoubtedly being made in all these
areas, the necessity for this Investigation to lay bare all of this may perhaps be questioned, both by
Trust staff (who undoubtedly feel beleaguered) and by others. There are two reasons to resist this
view. First, although the signs of improvement are welcome, they are still at an early stage and there
have been previous false dawns in the Trust; this emphasises the importance of understanding fully
the extent and depth of the changes necessary. Second, there is a clear sense that neither the Trust
nor the wider NHS has yet formally accepted the degree to which things went wrong in the past and
admitted it to affected families; until this happens, there is little prospect of those families accepting
that progress can be made.
These events have finally been brought to light thanks to the efforts of some diligent and courageous
families, who persistently refused to accept what they were being told. Those families deserve great
credit. That it needed their efforts over such a prolonged period reflects little credit on any of the
NHS organisations concerned. Today, the name of Morecambe Bay has been added to a roll of
dishonoured NHS names that stretches from Ely Hospital to Mid Staffordshire. 

This Report sets out why that is and how it could have been avoided. It is vital that the lessons, now plain to see, are learnt and acted upon, not least by other Trusts,  which must not believe that ‘it could not happen here’. If those lessons are not acted upon, we are destined sooner or later to add again to the roll of names."


March 2015