East Kent Hospitals Trust is reviewing its maternity services at QEQM Hospital in Margate and the William Harvey Hospital in Ashford following a series of highlighted failures in the care of women and their babies.
Significant concerns about maternity services at the trust have been raised as an inquest into the death of week old Harry Richford at QEQM in November 2017 is due to conclude.
The inquest was told of “panic” after Harry was born by emergency Caesarean section during which his heartbeat kept dropping. An independent report said he might have survived had there not been a delay in resuscitation. The trust has apologised and said his care “fell short of the standard” expected.
This week it also came to light that a damning report had been written after the trust asked the Royal College of Obstetricians and Gynaecologists to review the service in 2015. The Trust received the report in February 2016 but the Care Quality Commission says it did not have the full report until last year.
Review highlighted failures
The RCOG review highlighted a culture of “failing to challenge poorly performing consultants,” a lack of reviews for high risk women at QEQM and a reluctance to attend out of hours calls at the same site.
The report examined seven cases where serious incident reviews had been carried out. Two of these involved the death of babies. Another 16 cases included mothers developing severe pre-eclampsia.
The HSJ reports the review found midwives had used a drug to speed up labour without it being prescribed by a doctor; delays in carrying out a Caesarean section meant a baby was probably born in poorer condition; a lack of consultant involvement in a high-risk twin pregnancy where the woman developed severe pre-eclampsia and a case of one woman losing 3.2 litres of blood without consultant involvement until she was in theatre.
The report also found staff felt maternity services were not “on the priority list at board level.”
BBC investigation
An investigation carried out by the BBC claims seven baby deaths at the WHH and QEQM units since 2016 could have been preventable.
The investigation cites the deaths of Harry Richford; four day old Archie Powell, born on February 10, 2019 who died after a failure to spot group B streptococcus; Tallulah-Rai Edwards who was stillborn on January 28, 2019, after monitoring failures; Hallie-Rae Leek who died on April 7, 2017, aged four days, after struggles to find a heartbeat and delays in her delivery; Archie Batten, who died on September 1, 2019, shortly after birth when his mother, in labour, was told the QEQM maternity unit was closed and she should drive herself to the William Harvey in Ashford and two stillbirths in 2016 due to monitoring errors.
According to further research by The Independent between 2014-2018 there were 68 baby deaths at the trust for children aged under 28 days old and of those, 54 died within their first 7 days. There were 143 stillbirths and 138 babies suffered brain damage after being starved of oxygen during birth.
Maternity services at the Trust were rated “requires improvement” following an inspection in 2016 and remained at that grading in 2018 despite some improvements.
A new inspection was carried out by the CQC this month with a report due to be published soon.
‘Shocking’
County Council Karen Constantine, who was the Regional Head (South) for the Royal College of Midwives, said the report was evidence of “chaos of maternity services at East Kent Hospitals.”
She added: “The list of cases where mothers and their babies have suffered is frankly shocking. The trust needs to act quickly to reassure patients that the lessons from this report are identified and strategies are out into place to prevent repetition.
“It is particularly concerning to hear that maternity isn’t on ‘the priority list’ at Board level. For far too long maternity has been treated as a ‘Cinderella’ service.
“With a reorganisation threat hanging over the maternity service at QEQM the board should publicly state their commitment to providing a safe service for the women and families of Thanet.
“Women and their babies should always have access to consultants. Urgent steps need to be taken to ensure consultants are in place 24/7.
“The trust needs to promote the Speak Up Guardian so that mothers and others can speak out and get support doing so if they need to. Many women may feel particularly vulnerable during and after childbirth, adapting to the arrival of a baby or dealing with other challenging circumstances. The trust needs to do all that it can to make this easier, less onerous and accessible.
“It is also disappointing to hear that consultants are acting in breach of employment law with regard to being “given staff statements and allegedly confronted individual staff”. The trust needs to work with their Trade Unions to ensure all HR policies are up to date and that this cannot be repeated. This undermines staff confidence in the Trust as an employer.
“I would be happy to hear from anyone who feels they have been let down by the Maternity Services.”
Cllr Constantine said a maternity services champion should now be appointed at board level.
‘We wholeheartedly apologise to families’
The East Kent Hospitals Trust says it carried out a series of changes in 2017 and a restructure in 2018 but is now reviewing the service to make “rapid improvements.”
A Trust spokesperson said: “We recognise that we have not always provided the right standard of care for every woman and baby in our hospitals and we wholeheartedly apologise to families for whom we could have done things differently.
“We are reviewing our service with some of England’s leading maternity experts to make sure we are doing everything we can to make rapid improvements to maternity care in east Kent.”
The trust says changes already put in place include:
More consultants and senior clinician oversight of births at hospitals
Investment in more maternity and neonatal equipment
A comprehensive training programme in place for all maternity staff on identifying and safely supporting difficult births
Revised policy for recruiting and supervising temporary and junior doctors
Implemented a more comprehensive way of monitoring babies’ health during labour.
‘Investment and recruitment’
The spokesperson added: “We recognise, however, that the scale of change needed in our maternity service has not taken place quickly enough and we need to fully embed further learning and changes to our culture.
“We are now investing in ‘centralised CTG monitoring’, which will allow babies’ health during labour to be displayed on monitors in the labour wards’ midwifery stations and viewed by consultants elsewhere in the hospital or on call. This means staff can immediately be alerted to a potential problem and on call doctors will be able to provide expert opinion straight away, wherever they are.
“We will also recruit more doctors to further improve 24/7 care on our labour wards.
“We will be receiving support from the NHS Maternity Support Programme, which includes support from a Director of Midwifery from a Trust rated ‘Outstanding’ by the CQC; a Consultant Obstetrician and a Consultant Paediatrician, to support our maternity team to make rapid and sustainable improvements to our service.
“We want to provide an excellent standard of care to every mother and child who uses our service, and we will not rest until we, the public and our regulators are confident that we are doing so.
We express our heartfelt condolences to every family that has lost a loved one and we wholeheartedly apologise to families for whom we could have done thing differently.”
Reassurance
Around 7,000 babies are born under the care of East Kent Hospitals each year – just under 4,000 at the William Harvey Hospital, Ashford, and just under 3,000 at Queen Elizabeth The Queen Mother Hospital, Margate. Midwife to birth ratio meets the national recommended standard of 1:28.
The Trust says women who are currently expecting a baby can contact their named midwife if they would like reassurance about their current care.
Women who have been under the care of East Kent Hospitals’ maternity service in the past and have concerns about their care can contact 01233 651900.
Investigation
The CQC has confirmed it is investigating the situation. Under Regulation 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 a prosecution could be brought.
Ted Baker, Chief Inspector for hospitals at the Care Quality Commission (CQC) said: “CQC’s 2016 inspection rated maternity services at East Kent NHS Foundation Trust as Requires Improvement, identifying that staffing levels were impacting on the quality of patient care. That rating remained unchanged at our 2018 inspection, during which it was noted that the department had changed its approach to foetal monitoring training after concerns were identified.
“The trust remains subject to close monitoring and further inspections. We conducted an unannounced inspection of the Trust’s maternity services on 22 and 23 January 2020 and we will publish the findings of this inspection as soon as we are able to
“CQC is aware the inquest into the death of Harry Richford at East Kent Hospitals University NHS Foundation Trust is due to complete on Friday 24 January and await the findings of this inquest.
“CQC’s investigation is ongoing and no decision has been taken at this stage on whether we will prosecute the trust for a failure to provide safe care or treatment resulting in avoidable harm or a significant risk of avoidable harm.”
