Damning report into maternity scandal at East Kent Hospitals Trust probing deaths of up to 15 babies is due to be published TODAY with ‘harrowing’ accounts from more than 200 families
- Review into failings at East Kent Hospital Trust due to be published this morning
- Inquiry, led by Dr Bill Kirkup, looked at more than 200 cases dating back to 2009
- Report expected to describe how up to 15 newborns died due to poor care
- NHS trust boss warned maternity staff to expect a ‘harrowing report’
A ‘harrowing’ independent review looking into an alleged maternity scandal at East Kent Hospitals University NHS Foundation Trust’s probing the deaths of up to 15 newborns is due to be published this morning.
More than 200 families gave evidence to the review which is expected to expose a catalogue of serious failings including how newborns died needlessly due to poor care planning over several years, while parents’ concerns were ignored.
The report, led by Dr Bill Kirkup, has investigated the trust’s maternity services over a 11-year period from 2009 to 2020 was launched after the death of a baby in 2017.
It was triggered by the death of newborn Harry Richford in November 2017, with one midwife describing ‘panic’ during attempts to resuscitate him.
The review was triggered by the death of newborn Harry Richford in November 2017, with one midwife describing ‘panic’ during attempts to resuscitate him. The trust recorded his death as ‘expected’ and did not inform the coroner, but an inquest revealed he had died due to seven gross failings that amounted to neglect
Ahead of publication, Dr Kirkup said an expert panel investigating maternity care at East Kent Hospitals University NHS Foundation Trust heard a lot of ‘harrowing accounts’ from families during their work.
He told BBC Radio 4’s Today programme: ‘We’ve heard from a lot of families, a lot of harrowing accounts.
‘I’ll be setting all of that later for the families first and then for everybody, but there were a lot of common factors.
‘My heart goes out to everybody that this has happened to.’
Questioned about some families receiving care without compassion, he said: ‘I’ll be setting that out in some detail in the recommendations.
The families of two babies who died at a hospital trust under investigation for up to 200 incidents involving mothers and infants say staff blamed them
‘I think what I would say at this point in the morning is I understand that people work under pressure, that doesn’t excuse or explain being rude or aggressive. That’s a different set of problems.’
Dr Kirkup, who also led the investigation into mother and baby deaths in Morecambe Bay in 2015, will be issuing his report to the families involved prior to publishing the report publicly.
He added that he ‘did not imagine’ he would be talking about similar circumstances again following his investigation into Morecambe Bay in 2015.
He said: ‘When I reported on Morecambe Bay maternity services in 2015, I did not imagine for one moment that I would be back in seven years’ time talking about a rather similar set of circumstances and that there would have been another two large, high-profile maturity failures as well on top of that.
‘This cannot go on. We have to address this in a different way.
‘We can’t simply respond to each one as if it’s a one-off, as if this is the last time this will happen. We have to do things differently.’
Tom and Sarah Richford, whose son Harry died seven days after he was born in November 2017, leavong Folkestone Magistrtes Court where East Kent Hospitals University NHS Foundation Trust pleaded guilty to failing to provide safe care and treatment in 2021
Harry Richford, whose death prompted the inquiry into East Kent Hospitals Trust, died at the Queen Elizabeth the Queen Mother hospital (pictured in November 2017
Meanwhile, Tracey Fletcher, chief executive of East Kent Hospitals University NHS Foundation Trust, has warned maternity staff to expect a ‘harrowing report’.
The Government is expected to respond later today in the Commons to the report, which was commissioned by NHS England in 2020 following growing concerns about quality of care.
Maternity staff are accused of ‘blaming mothers for the deaths of their babies’ on eve of devastating report into hospital trust
The families of two babies who died at a hospital trust under investigation for up to 200 incidents involving mothers and infants say staff blamed them.
Helen Gittos and Kelli Rudolph lost daughters while in the care of East Kent Hospitals.
Mrs Gittos, who lost her daughter Harriet in 2014, said she was ‘treated dismissively, contemptuously and without a desire for understanding’.
Helen Gittos pictured
In a statement, she added: ‘It is hard enough to come to terms with the death of a child. It is even harder when you are implicitly blamed for what happened.’
Dr Rudolph and Dunstan Lowe lost their daughter Celandine when she was five days old after she was delivered at William Harvey Hospital in Ashford in 2016. They claimed the hospital’s response had added to their grief.
Dr Rudolph said: ‘Their response to their poor medical judgments was to blame me. That is what I’ve had to live with.’
Mr Lowe added that he hoped the Independent Investigation Into East Kent Maternity Services would be ‘the bridge between the pain we’ve experienced and the anger and the urgency for the things that are broken to be repaired immediately.’
The independent review was launched after death of newborn Harry Richford in November 2017.
The family of baby Harry Richford, who died a week after his birth at the QEQM in 2017, have long campaigned for answers after saying their concerns were repeatedly brushed aside by hospital managers.
The trust was fined £733,000 last year for failures in Harry’s care after he suffered brain damage.
A previous inquest ruled his death was ‘wholly avoidable’ and found more than a dozen areas of concern, including failings in the way an ‘inexperienced’ doctor carried out the delivery, followed by delays in resuscitating him.
One midwife described ‘panic’ during attempts to resuscitate Harry, while a staff nurse said the scene was ‘chaotic’.
Following Harry’s death, the East Kent Trust recorded his death as ‘expected’ and did not inform the coroner.
Only the efforts of Harry’s family eventually brought his death to the attention of coroner Christopher Sutton-Mattocks.
Last October, the Care Quality Commission (CQC), which inspects hospitals, again expressed concerns over the trust, which it has repeatedly ranked as ‘requires improvement’.
It said that during unannounced inspections in July 2021 there were not enough midwifery staff and maternity support workers to keep women and babies safe.
Inspectors said staff were feeling exhausted, stressed and anxious, while some community midwives had taken on additional work in the acute units, which meant they were sometimes working 20-hour days.
In 2020, the Healthcare Safety Investigation Branch (HSIB), which investigates NHS harm, detailed how, despite repeated warnings from its investigators, improvements were not made to maternity care at the trust.
The HSIB began working with East Kent’s maternity units in 2018 and identified ‘recurrent safety risks’ including over how CTG readings were interpreted, baby resuscitation, recognition of deterioration in mothers and babies, and the willingness of staff to escalate their concerns to more senior medics.
From December 2018, the HSIB said it ‘engaged frequently’ with the trust about its concerns but kept seeing the same things happening.
In August 2019, it asked the trust to self-refer to the CQC and regional health bosses.
The families of babies who received poor care at the trust will be the first to read the findings of Dr Kirkup’s inquiry.
Among them are expected to be the parents of Archie Batten, who died in September 2019 at the QEQM.
A coroner ruled he died of natural causes ‘contributed to by neglect’ and ‘gross failure’.
The report, which was delayed by the Queen’s death, is expected to say avoidable baby deaths happened because recommendations following other NHS maternity scandals were not implemented.
The trust said a statement would be issued when the report is published.
It was commissioned after up to 15 babies died at the William Harvey Hospital in Ashford and Queen Elizabeth The Queen Mother Hospital in Margate.
Timeline: What happened at East Kent Hospitals Trust?
2009: East Kent Hospitals NHS Trust becomes a foundation trust, with five hospitals and community clinics serving a local population of around 695,000 people.
2012: Serious problems at the trust were first highlighted when newborn Harry Halligan died at the William Harvey Hospital in Ashford.
His twin sister was first delivered without any major complications but Harry was delivered by emergency caesarean after failed attempts to use forceps.
Harry’s mother, Alison Halligan, said the decision was taken ‘a bit late’ and the hospital did not seem prepared to deliver twins. After numerous investigations, the trust told Harry’s parents Dan and Alison Halligan they would learn lessons.
2014: The trust is put into special measures following an inspection by the Care Quality Commission after the regulator rated its care, including maternity services, as inadequate.
Meanwhile, investigations into eight neonatal deaths began.
2015: The Morecambe Bay report which investigated failures at a Cumbrian hospital that led to the deaths of 11 babies is published.
Written by Dr Bill Kirkup, who has led the East Kent independent review, he said it was vital lessons were learnt by other trusts.
2016: A maternity improvement plan for the trust is launched after a review by the Royal College of Obstetricians and Gynecologists finds significant issues.
2017: Harry Richford died at seven days old after an emergency delivery at The Queen Elizabeth the Queen Mother Hospital in Margate.
2018: Failings are also uncovered by an investigation undertaken by the Healthcare Safety Investigations Branch.
2020: The death of baby Harry Richford was ‘wholly avoidable’, the coroner leading his inquest ruled. Following the conclusion, the trust said it accepted the coroner’s findings and was ‘deeply sorry’ for its failings in Harry’s care.
During the inquest, it also emerges that the trust failed to complete 21 recommendations made by the 2016 review conducted by the Royal College of Obstetricians and Gynecologists.
An independent review into the trust from 2009 to 2020, led by Dr Kirkup, is announced.
2021: The trust admits failing to provide safe care and treatment for Harry Richford at Folkestone Magistrates Court and is fined £733,000 for failing to provide safe care and treatment for Harry Richford and his mother, Sarah Richford.
2022: Result of the independent review is published.
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