Sarah and Tom Richford with their son Harry who died at the Queen Elizabeth the Queen Mother Hospital
(Picture: PA)Failings in the maternity services inside a Kent NHS trust contributed to the deaths of newborn babies, a long-awaited report has said.
Published on Wednesday, the Dr Bill Kirkup-led investigation into Margate and Ashford hospitals examined more than 200 cases of poor care dating back to 2009 and has said newborns died unnecessarily.
The look into maternity standards at East Kent Hospitals University Foundation Trust was commissioned in 2020 following growing concerns about the quality of care.
The trust which represents the Queen Elizabeth The Queen Mother Hospital (QEQM) in Margate and the William Harvey Hospital in Ashford - where the incidents happened - has “apologised unreservedly”.
The report found “dozens” of babies died or were left brain damaged by poor care.
"An overriding theme, raised us with time and time again, is the failure of the trust's staff to take notice of women when they raised concerns, when they questioned their care, and when they challenged the decisions that were made about their care," the report said.
Of 202 cases reviewed by the experts, the outcome could have been different in 97 cases, the inquiry found.
The commission followed the case of Harry Richford in 2017 who died a week after being born when he suffered brain damage following mistakes made during his mother’s labour.
A coroner ruled the death was “wholly avoidable” and the trust was fined £733,000.
There was also the case of Laura Cooke whose four-week-old baby boy Luchii was discharged without treatment after a doctor diagnosed the lung infection bronchiolitis. This turned out to be tuberculosis and caused Luchii’s death in December 2019.
The Care Quality Commission has consistently ranked the trust’s maternity as ‘requires improvement’ and has commented on there not being enough midwives to keep it functioning to a high standard.
Dr Kirkup, who chaired the report, also led the investigation in 2015 after deaths of mothers and babies at the Morecambe Bay hospital.
He said: "When I reported on Morecambe Bay maternity services in 2015, I did not imagine that I would be back reporting on a similar set of circumstances seven years later.
Whilst I have one or two other things in my in-tray today, it’s important to reflect on the horrific report on failings in maternity care at East Kent hospital.
— Jeremy Hunt (@Jeremy_Hunt) October 19, 2022
"What has happened in East Kent is deplorable and harrowing."
He added he had met with affected families who displayed "a great deal of emotion and substantial amount of anger".
The report also follows the Ockenden report after the deaths of 201 babies at Shrewsbury and Telford NHS trust.
In East Kent, for 69 of these 97 cases, it is predicted the outcome should reasonably have been different and could have been different in a further 28 cases.
Of the 65 baby deaths examined, 45 could have had a different outcome if nationally recognised standards of care had been provided.
When looking at 33 of these 45 cases, the outcome would reasonably expected to have been different, while in a further 12 cases it might have been different.
Meanwhile, in 17 cases of brain damage, 12 (72 per cent of cases) could have had a different outcome if good care had been given, of which nine should reasonably have been expected to have had a different outcome.
In nearly half of all cases examined by the panel, good care could have led to a different outcome for the families.
Danielle Clark, mother to Noah whose case was part of the inquiry, said: "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."
Trust chief executive Tracey Fletcher said the families were “failed” by the actions and said everybody is “committed” to learning from the incidents.
“I want to say sorry and apologise unreservedly for the harm and suffering that has been experienced by the women and babies who were within our care, together with their families.”
She said progress towards improvement has been made, adding: “Our thoughts remain with those who have shared their experiences. We are grateful to them.”
Statement from @SirRogerGale on East Kent Maternity Report. Says there have been serious failings in middle-management that remain to be resolved. “Unacceptable” lack of honesty and transparency @bbcsoutheast pic.twitter.com/zmcDf6xEaG
— Charlotte Wright (@charlotte_bbc) October 19, 2022
Sir Roger Gale, North Thanet MP - whose constituency covers Margate, tweeted a statement in which he called out the “lack of honesty and transparency” within the trust.
He pledged to meet with leaders and write to the health secretary Therese Coffey about the issue.
