Poor care may have led to the deaths of 45 babies, with 97 cases of harm, injury or deaths to mothers overall, which may have been avoided in east Kent, a major maternity inquiry has found.
The review looked at more than 200 cases spanning more than a decade of maternity failings by East Kent Hospitals University Trust and found a “pattern of recurring harm” at the trust.
It was found that in 97 out of the 202 cases, the outcome for the mothers or babies could have been different. Of those, 45 babies’ deaths may have been avoided, 12 babies may not have suffered brain damage and 23 mothers may not have died or been injured.
In 54 patients’ care they found failings but determined this would not have changed the outcome.
The review was led by Dr Bill Kirkup, who also led the 2015 review into the failings at Morecambe Bay hospital that led to the deaths of 16 babies and three mothers.
Speaking at a press conference, Dr Kirkup said what had happened in east Kent was “deplorable” and “harrowing”.
“When I reported on Morecambe maternity services in 2015. I did not imagine that I would be back reporting on a similar set of circumstances seven years later,” he said.
If you have been impacted by poor maternity care or failings email rebecca.thomas@independent.co.uk
Dr Kirkup has said in a letter to the health secretary Therese Coffey that the failings in Kent are not a “one-off”, warning if the NHS does not begin to tackle poor maternity care, more inquiries will follow.
The review of the trust’s performance between 2009 and 2020 found that failings were visible to senior managers and the trust board, and that problems could have been acknowledged and tackled.
The report, published on Wednesday, found:
- Gross failures in team working, with a series of problems between midwives, obstetricians, paediatricians and neo-natal services
- “Dysfunctional teamworking” and poor behaviour clouded the response to safety incidents
- “Uncompassionate care”
- Repeated failures to listen to families
- Problems among the midwifery staff and obstetric staff were known but not addressed
- Regulatory system failed to identify shortcomings early enough and clearly enough
The probe, led by Dr Kirkup, was commissioned by the government after The Independent revealed more than 130 infants suffered brain injuries during birth at the trust over several years.
Dr Kirkup and the review team have called for national action and warned, “This must be the last such moment of failure, with the lessons leading to improvement not just locally but nationally.”
The scandal was exposed by the family of baby Harry Richford who died after a catalogue of errors by maternity staff in November 2017. A coroner ruled his death was the result of neglect and “wholly avoidable”.
In a landmark case, the trust was fined £761,000 following prosecution by the Care Quality Commission for the trust’s failure to protect baby Harry Richford and his mum Sarah Richford from avoidable mistakes that led to the child’s death.
In October last year, the CQC found staff shortages at the hospital had left midwives working 20-hour days with little time for a break.
The report follows the Shrewsbury Maternity scandal review published earlier this year, which found failings at Shrewsbury and Telford Hospital Trust led to the deaths and brain injury of more than 250 babies.
‘I wasn’t listened to’
Emma Robinson’s daughter Daisy died in 2014, just hours after her birth.
Speaking to The Independent, she described how a week before her induction date she had to go to hospital due to migraines, high blood pressure, swelling and protein in her urine.
However, she was told to keep her original induction date, and 48 hours before it she began experiencing labour pains. When she got to hospital for her inducement date, her blood pressure was so high she had to have an epidural.
She recounted events during her labour: “At some point they came and spoke to me and they basically said you’re not progressing, we’re going to take the hormone drip away so you can sleep. You need a C-section, but your baby is not priority. There are two other mums in front of you and they need the C-section. They need their C-section because their babies are poorly and your baby is fine.”
She added: “I was just 19. I felt like they only listened to me when my mum was in the room because my mum was a nurse. I didn't feel listened to. I feel I was stereotyped. I feel like no matter what I went there with, they knew better. I think that is another thing that needs to change, the voice of the parent.”
Shortly after Daisy was born, staff had to rush her for resuscitation and tragically, more than an hour later Emma was told she was not responding.
After Daisy’s death, Ms Robinson was placed on a ward with other women who had given birth and had their babies.
She said: “I just felt so numb to the world the whole time and everything that went on was so fuzzy. I cried so much. I just think it’s disgusting now when I look back on it and I suffer with really bad anxiety since losing Daisy. It was really emotional and really hard to have to listen to other people, knowing that I’m not going to have my baby.”
A coroner later determined Daisy had died from sudden infant death syndrome. However, Emma said her placenta was not kept for testing and so pre-eclampsia could not be determined.
A trust investigation into Daisy’s death, Ms Robinson claims, incorrectly recorded that she had refused a C-section.
She said: “We were constantly told they were short-staffed on the night, we were constantly told that Daisy had to wait because when they watched the heartbeat... we were constantly told Daisy was fine, she was less of a priority. These other two mums were a priority – their babies are still here but mine isn’t.
“I feel they failed both of us and I feel that Daisy paid the price. I feel like it’s as raw as it was in 2014 because haven’t got the answers... I don’t want other mums to go through this. Hopefully, this report will change the care in maternity.”
