A damning report into maternity services of an NHS Trust has slammed the "unacceptable and distressingly poor" care which led to the tragic deaths of several babies who could have been saved.
The report was ordered following the deaths of dozens of babies at the East Kent Hospitals University NHS Foundation Trust, with teams examining incidents between 2009 and 2020.
Tragically the independent inquiry into maternity at East Kent Hospitals University NHS Foundation Trust found of 202 cases reviewed, 97 should have had different outcomes and that 45 of the 65 baby deaths, or 69% of these cases, could have been saved.
When it looked into 33 of the 45 cases the report found 33 would have been "reasonably expected) to be different, while 12 might have been different. One woman whose baby died was told it was "God's will".
The report said: "Those responsible for the services too often provided clinical care that was suboptimal and led to significant harm, failed to listen to the families involved, and acted in ways which made the experience of families unacceptably and distressingly poor.
"It is in the nature of childbirth that most mothers are healthy, and, thankfully, their babies will be too. But so much hangs on what happens in the minority of cases where things start to go wrong, because problems can very rapidly escalate to a devastatingly bad outcome."
East Kent’s main maternity services are at the Queen Elizabeth The Queen Mother Hospital (QEQM) in Margate and the William Harvey Hospital in Ashford.
MP Nadine Dorries, the former minister for patient safety, ordered the independent investigation into East Kent Hospitals.
Chillingly the report, led by Dr Bill Kirkup, also found maternity services were "not safe" because of divisions among the midwives, which included bullying.
Speaking at a press conference at the Leas Cliff Hall in Folkestone, Danielle Clark, whose son Noah was born at QEQM, described the difficult labour and birth she went thorough.
She said: “I had a son in 2013, I was induced but the reason I was induced was never communicated.
“The induction then took three days, I should have been offered an emergency C-section, but instead they gave me too much induction gel, over the Nice (National Institute for Health and Care Excellence) guidelines.
“He ended up in special care, in resuscitation. At eight weeks old he had to have emergency surgery because things had been missed, he wasn’t gaining weight, he was dying in front of our eyes basically.
“People need to be held accountable. Things have got to change, babies are dying just through bad care and pure neglect.
“Midwives at the moment are short staffed but it’s almost like they’re treating every patient as textbook material, but anybody who has any sense knows no patient is textbook.
“I wouldn’t say I’ve got closure because having experienced neglect again eight years later with the birth of my third son last year, it’s very infuriating to think things still haven’t changed.”
The report said the leadership at the hospitals regarded themselves as "victims of geography, recruitment difficulties and a neglected estate."
It added: "We have found the origins of the harm we have identified and set out in this report lie in failures of teamworking, professionalism, compassion and listening."
It was originally due to be published in September but was delayed after the death of Queen Elizabeth II.
The report pinpointed "gross failures of teamwork" at both hospitals, finding problems between the midwives, obstetricians, paediatricians involved in maternity and neonatal services.
It reads: "Some staff have acted as if they were responsible for separate fiefdoms, cultivating a culture of tribalism.
"There have also been problems within obstetrics and within midwifery, with factionalism, lack of mutual trust and disregard for other points of view.
"We found clear instances where poor teamwork hindered the ability to recognise developing problems, and escalation and intervention were delayed.
"The dysfunctional working we have found between and within professional groups has been fundamental to the suboptimal care provided in both hospitals."
The report suggested a number of recommendations, including the creation of a taskforce.
Among the cases looked into was that of Harry Richford, who died a week after his birth in November 2017 at the QEQM.
At an inquest into Harry’s death coroner Christopher Sutton-Mattocks listed a series of errors he found with the care given at the hospital.
He gave a narrative conclusion that Harry's death was contributed to by neglect and had been "wholly avoidable".
At the time his devastated parents said the death should be a "turning point" for the NHS trust involved.
