East Kent maternity deaths: Babies might have survived with better care

Harry Richford would have survived but for failings by the hospital

Up to 45 babies might have survived if they had received better care at East Kent NHS Hospitals Trust, a damning independent review has found.

It uncovered a "clear pattern" of "sub-optimal" care that led to significant harm, and said families were ignored.

The medical experts reviewed an 11-year period from 2009 at two hospitals in Margate and Ashford.

The trust, which has been heavily criticised by parents, apologised for the "harm and suffering".

The independent review, which was chaired by Dr Bill Kirkup CBE, added the trust had given the appearance of "covering up the scale and systemic nature" of its problems.

• 'No-one joined the dots' says grandad who exposed scandal

Bex Walton, whose son Tommy died in 2020, two days after being born at the William Harvey Hospital in Ashford, said "sorry is not good enough".

She said: "I will never be able to forgive. Nothing they do now will be good enough because my boy will never be with me ever again."

Chancellor Jeremy Hunt said the scandal was "simply unthinkable". Health minister Dr Caroline Johnson apologised to the families and said the government was committed to preventing future tragedies.

Dr Bill Kirkup said his team's findings were shocking

Investigators said the trust wrongly took comfort from the fact most births at East Kent ended with no damage to mother or baby.

They found harm was not just restricted to physical damage, and there was a repeated lack of kindness and compassion even in the aftermath of injuries and deaths.

Dr Kirkup's team also found "gross failures" of team-working across the trust's maternity services, with some staff acting as if they were responsible for "separate fiefdoms, cultivating a culture of tribalism".

"The dysfunctional working we have found between and within professional groups has been fundamental to the sub-optimal care provided in both hospitals," the report said.

• Troubled maternity service still beset by problems

• Mothers felt blamed by medical staff

• Harry Richford's family's five-year fight for justice

A series of failings emerged during the inquest of Harry Richford, who died seven days after being born in 2017.

The hearing in January 2020 found Harry's death at The Queen Elizabeth the Queen Mother Hospital (QEQM) in Margate was "wholly avoidable".

The trust has apologised for Harry's death, which it initially said was "expected". However it was not the first incident of its kind.

Harry Halligan nearly died in 2012 following mistakes during his delivery at the William Harvey.

Afterwards, the trust was put into special measures by the Care Quality Commission, which rated its maternity services as "inadequate".

Analysis

By Mark Norman, BBC South East health correspondent

Many families believed they were treated with contempt by the hospital trust and its staff.

Treated with contempt when they asked why their baby had died.

Treated with contempt when they asked for an investigation or a coroner's inquest.

Treated with contempt when they questioned the trust about its responses and treated with contempt when they asked why investigations were taking so long.

But looking beyond the treatment they received, every family I have spoken to wants change.

Systemic, transparent change in the way the hospital trust runs its maternity departments, in the way it handles mistakes and errors on the part of its staff. And change in the way it treats families.

Directives for improvement were made, but the trust failed to implement almost all the recommendations.

Harry Richford's family claim their baby might not have died if the trust had learned from the case of Harry Halligan, and have spent years demanding systemic change at East Kent's maternity units.

Speaking to reporters following the release of the report, Dr Kirkup said the most troubling aspects of his review were the attitude and behaviours of some trust staff towards families with legitimate complaints.

Dr Kirkup said 45 of the 65 baby deaths that occurred during the review period could have had a different outcome.

He said the scale of the failings at the trust was "deplorable and harrowing" and that there was anger among families he had met.

On at least eight occasions over a 10-year period, the trust board was presented with "inescapable signals" there were serious problems, said Dr Kirkup, who has previously led several reviews, including chairing the investigation of Morecambe Bay maternity services.

A prominent theme which emerged during the East Kent review was the presence of "challenging personalities, big egos, huge egos", with one group dubbed "the A-team".

Trust chief executive Tracey Fletcher apologised for the trust's failings

A lack of compassion was also highlighted, with one woman "dismissively" told during an antenatal check to look up extra information on Google.

Trust chief executive Tracey Fletcher said she apologised unreservedly for the "harm and suffering" caused.

"These families came to us expecting that we would care for them safely, and we failed them," she said.

Ms Fletcher said the trust would act on the report, on behalf of "those who we will care for in the future and for our local communities".

"I know that everyone at the trust is committed to doing that," she said.

Ms Fletcher added that the trust had increased numbers of midwives and doctors, and invested in staff training and in listening to and acting on feedback from the people who receive its care.

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