As many as 45 dead babies may have survived had they received proper care at a major hospital trust amid warnings of more NHS maternity scandals.
A damning report also found 12 cases of brain damage could have been avoided at East Kent Hospitals University NHS Foundation Trust.
Top obstetrician Dr Bill Kirkup, who chaired of the latest inquiry into maternity, warned: “If we do not begin to tackle this differently, there will be more.”
He told of “harrowing” accounts from families and of 202 cases examined from between 2009 and 2020, concluded that better care could have made a difference in 97 cases.
His Government-commissioned review found there was no evidence the trust had improved during the period and highlighted a refusal to learn lessons.
Dr Kirkup said: “The findings of the investigation are stark and the conclusions are shocking and uncomfortable.
“It is too late to pretend that this is just another one-off, isolated failure, a freak event that will ‘never happen again’.”
Infants died while others were left badly hurt due at two major Kent maternity units, one in Margate and one in Ashford.
The report identified a failure to implement sweeping 2015 recommendations following the Morecambe Bay maternity scandal, also headed by Dr Kirkup, is allowing failings to continue at other hospitals.
The latest probe follows the worst ever NHS maternity scandal at Shrewsbury and Telford Hospitals NHS Trust where more than 200 avoidable deaths occurred and dozens of babies were left brain damaged.
It was uncovered in a review by top midwife Donna Ockenden who has since been made head of an ongoing probe in to Nottinghamshire hospitals following the deaths and injuries of dozens of babies and mothers during or shortly after birth.
Dr Kirkup 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.
“What has happened in East Kent is deplorable and harrowing.”
The Care Quality Commission has consistently ranked the trust’s maternity as ‘requires improvement’ and has commented on there not being enough midwives.
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.
“I hope this doesn’t happen to other families, but why has it taken so many babies, why has it taken so many years?
“Why would they change now?”
Erika Emery-Madiro, who lost her son at the William Harvey Hospital in Ashford in 2012, said: “Your heart breaks for everyone. At the end of the day, no-one should have to lose a child, or even have damage caused to that child.
“Your heart breaks, you just cannot put it into words at all.”
A series of failings emerged during the inquest of Harry Richford, who died seven days after being born in 2017 before his family launched a campaign to get the coroner to investigate.
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 died in 2012 following mistakes during his delivery at the William Harvey Hospital in Ashford.
Afterwards, the trust was put into special measures by the Care Quality Commission, which rated its maternity services as “inadequate”.
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 death of Harry Halligan.
The East Kent report, unveiled to families at a hotel in Folkestone yesterday(Wed), identified “gross failures of team working”. One assessor told investigators the trust had “the worst culture I’ve ever seen”.
A woman, whose baby had died, was told: “It’s God’s will; God only takes the babies that he wants to take.”
Another woman could feel herself being cut open due to inadequate pain relief, while another, who asked why an additional attempt at forceps delivery was to be made, was “brusquely told that it was ‘in case of death’.”
The report found that some obstetricians had “huge egos” while midwives showed “cliquey behaviour” and there was an in-group, “the A-team”.
Dr Kirkup said a culture of “deflection and denial” within NHS trusts when they are questioned about potential cases of substandard care “needs to be addressed”.
He said: “This is a cruel practice that ends up with families being denied the truth.
“That’s a terrible way to treat somebody in the name of protecting your reputation.”
Dr Kirkup has called for a “Hillsborough law” to force hospitals to be transparent when failings occur.
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He said: “It would place a legal duty on public bodies to be truthful and not conceal problems when they arise.”
“It seems a mystery that this hasn’t been enacted and I think it should be.”
In a letter to Health Secretary Therese Coffey and NHS chief executive Amanda Pritchard, Dr Kirkup said the report told the truth of what had happened and must be “catalyst” for tackling “embedded, deep-rooted problems” in NHS maternity care.
He added: “Since the report of the Morecambe Bay Investigation in 2015, maternity services have been the subject of more significant policy initiatives than any other service.
“Yet, since then, there have been major service failures in Shrewsbury and Telford, in East Kent, and (it seems) in Nottingham. If we do not begin to tackle this differently, there will be more.”
The trust runs the Queen Elizabeth The Queen Mother Hospital (QEQM) in Margate and the William Harvey Hospital (WHH).
Chief executive Tracey Fletcher said: “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, as described in today’s report.
“We must now learn from and act on this report; for those who have taken part in the investigation, for 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.”
Of 202 cases reviewed by the experts, the outcome could have been different in 97 cases, the inquiry found.
In 69 of the 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 babies could have lived or may have lived if they had been offered nationally recognised standards of care.
When looking at 33 of these 45 cases, the outcome would reasonably be expected to have been different, while in a further 12 cases it might have been different, the report said.
Meanwhile, in 17 cases of brain damage, 12 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.
Health minister Caroline Johnson apologised to families and said the NHS was “committed to preventing families from going through the same pain in future”.
