East Kent hospital baby deaths: Years of failures over baby deaths led to review

The report examines dozens of incidents at East Kent Hospitals Trust

As the findings of an inquiry into maternity services at East Kent Hospitals Trust are published, the BBC looks into the background of the scandal, and how it took more than a decade to be fully exposed.

What happened at the hospitals?

The independent review by Dr Bill Kirkup examines the trust during an 11-year period from 2009, but serious problems were first highlighted when Harry Halligan nearly died in 2012 due to mistakes during his delivery.

His twin sister was delivered without major complications, but the William Harvey Hospital in Ashford was not prepared for twins.

Numerous investigations into the trust followed, and East Kent Hospitals told Harry's parents Dan and Alison Halligan they would learn lessons.

But in 2017 similar failings were uncovered when Harry Richford died at seven days old after another emergency delivery at The Queen Elizabeth the Queen Mother Hospital (QEQM) in Margate.

The trust admitted failing to provide safe care and treatment following an inquest and a review.

Harry, seen with his parents Sarah and Tom Richford, died aged just seven days

Other incidents then surfaced both at the QEQM and the William Harvey Hospital, and up to 15 baby deaths at the trust were investigated.

The death of Harriet Gittos, who passed away at eight days old in August 2014, was one of the incidents being probed.

Investigators also examined the death of Freddie White in April 2016. He had twin-to-twin transfusion syndrome and was not getting enough blood supply, but no action was taken, it was discovered.

The trust admitted he might have survived if he had been delivered earlier.

Kelli Rudolph and Dunstan Lowe lost their daughter Celandine at five days old, after she was born at the William Harvey in 2016.

The couple said they were blamed by the hospital trust for the deaths.

It took staff too long to resuscitate Hallie-Rae Leek

Hallie-Rae Leek died in April 2017, aged four days.

She required resuscitation at birth, but it took too long and she suffered irreparable damage.

Fletcher Aiken died in August 2017 after staff failed to believe his mother Katy King was in early labour.

He was born by emergency caesarean section, but died aged 13 days.

Archie Powell died from a group B streptococcus infection four days after he was born

Archie Powell died at four days old on 10 February 2019.

He was initially treated for a bowel condition but was actually suffering from the infection group B streptococcus.

Tallulah-Rai Edwards was stillborn in January 2019.

Despite her mother flagging the baby's slowed movement and hospital staff struggling to get a good heart-rate reading, midwives sent her home. Tallulah-Rai died in the womb two days later.

Katy King said staff failed to believe she was in labour as she was only 28 weeks pregnant

In a similar case Reid Shaw died in November 2019, after his mother Kirsty Stead reported reduced movement with her baby, and severe pain.

She was told to take paracetamol and go to sleep, but when she went to the hospital later her son died.

Archie Batten was another victim of "gross failures" at the trust.

He died after his mother Rachel Higgs was turned away from the QEQM because the maternity unit was full in September 2019.

Alisha Pegg was also sent home from the William Harvey in February 2021.

Her premature daughter, Grace, was "neglected" by hospital staff, and Ms Pegg was told her baby was dead, then alive, before she died hours later.

What are the families calling for?

This scandal was unearthed mainly through the efforts of the Richford family over the past five years.

Initially they were motivated by finding the truth over the reasons Harry died.

Once they realised the boy's death might have been avoided if the trust had learned from previous incidents they sought systemic change in the East Kent maternity department so others could avoid their trauma.

Derek Richford, Harry's grandfather, said he did not want to hear more apologies from the trust.

"It's not good enough, they've got to make changes," he said.

"It's become absolutely clear, that had the trust learned from the errors they made at a very early stage, and I'm talking 2010, 2011, Harry and a whole lot more kids would be alive today."

Derek Richford said an apology is no longer 'good enough'

Who is leading the review?

Dr Bill Kirkup is leading a team of five experts who make up the panel of experts investigating the trust.

He previously reviewed failings at Morecambe Bay NHS Trust, and in 2015 produced a report into the "dysfunctional" unit at Furness General Hospital in Barrow following the deaths of three mothers and 16 babies.

The panel has representatives from the fields of obstetrics, midwifery, neonatal medicine, clinical governance and information management.

Timeline:

• 2009: East Kent Hospitals NHS Trust becomes a foundation trust.

• 2014: The trust is put into special measures following an inspection by the Care Quality Commission (CQC) which rated its care, including maternity services, as inadequate. Investigations began into eight neonatal deaths.

• 2015: The Morecome Bay report is published into failures at a Cumbrian hospital that led to the deaths of 11 babies. Written by Dr Bill Kirkup, who heads the East Kent investigation, he said it was vital these lessons were also learnt by other trusts.

• 2016: A Royal College of Obstetricians and Gynaecologists review finds significant problems across East Kent hospitals. A Maternity Improvement Plan is launched, overseen by NHS England.

• 2018: The Healthcare Safety Investigations Branch investigates and also finds failings.

• 2020: The inquest into the death of Harry Richford sees various reports and concerns laid bare in front of the coroner. It emerges the trust failed to complete 21 recommendations made by the 2016 RCOG review. A new independent review, headed by Dr Kirkup, is announced.

• 2021: The trust is fined £733,000 for failures in its care of Harry Richford.

• 2022: Result of the independent review published.

What does the Trust say?

The East Kent Hospitals Trust previously said: "The death of any baby in a hospital maternity unit touches all of us. The loss of a life before it has barely begun is always deeply saddening. When it involves serious failings in the provision of care - as it did in the case of Harry Richford - it's not just heart-breaking, it's a tragedy.

"It was clear that for some time the NHS had not provided all the people of East Kent with the high level of maternity care they need and deserve. We apologise from the bottom of our hearts to Harry's parents, to the rest of his family and to other families we have failed."

Niall Dickson, chairman of the trust, said following prosecution by the CQC: "Harry's parents expected that they would return home with a healthy baby and we failed them. Those of us who have not been through such a tragedy cannot appreciate what they have suffered.

"We fully acknowledge the mistakes that we made."

The trust said it had welcomed the independent investigation by Dr Kirkup and his team.

Mr Dickson said the trust was "determined to learn any lessons" that emerged from Dr Kirkup's investigation.

If you have been affected by any of these issues, you can visit the BBC's Action Line, or contact the Samaritans.

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