East Kent Hospitals Trust has set up a board sub-committee and commissioned an external review of maternity services following an inquest into the death of baby Harry Richford just a week after his birth at Margate’s QEQM Hospital in November 2017. The coroner ruled Harry’s death had been “wholly avoidable” and neglect had been a contributory factor.
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.
Today (February 10) more cases have come to light.
Calls have been made for a public inquiry with the issue due to be discussed in Parliament today (February 10).
Losses
Dr Helen Gittos- her baby is Harriet Gittos who was born on the 03/08/14 at QEQM and died on 11/08/14. Her case was one of those reviewed in the RCOG report.
The Trust said:“We continue to offer our heartfelt condolences to Harriet’s parents.
“In 2018, our new Head of Midwifery reviewed the documentation that was completed following Harriet’s sad death and subsequently met with Harriet’s parents and doctors to discuss Harriet’s care.
“We are extremely sorry that Dr Gittos feels her voice has not been properly heard and we accept the Royal College of Obstetricians and Gynaecologists’ view that we could have done more to respond to Dr Gittos’ wishes and help her labour in a calm, low-risk environment as much as possible. This is something we are working hard to change.
“We know this has been an exceptionally difficult time for Harriet’s family and we are extremely sorry for their sad loss.”
Katy King- her baby was Fletcher Aiken was born 3/08/17 and died on 16/08/17
The Trust’s said:“We continue to offer our heartfelt condolences to Fletcher’s family for their devastating loss. We carried out a thorough review of Fletcher’s care following his sad death in 2017. There was no evidence of any omissions in care. The Parliamentary and Health Service Ombudsman is currently investigating the family’s complaint.”
Kirsty Stead and Jack Shaw- their son was Reid Shaw who was stillborn on the 8/11/19 at QEQM
The Trust said: “We offer our heartfelt condolences to Reid’s family. Our thoughts and deepest sympathies go out to them.
“We apologise that they have concerns about Reid’s care. We have started a thorough investigation into the care that Kirsty and Reid were given and we will involve Reid’s parents fully and honestly in the investigation as it progresses.”
Nicola Grimmett- her son was Freddie White- stillborn on 12/04/16 at QEQM
The Trust said: “We are truly sorry for the omissions in Nicola and Freddie’s care. With sadness, we accept that Freddie’s death might have been avoided had we acted differently and we wholeheartedly apologise for this.”
The Trust has worked collaboratively with the Healthcare Safety Investigation Branch (HSIB) since it began working on maternity care in April 2018. From April 2018, all Trusts have been required to refer any incidents that meet HSIB’s criteria to HSIB for investigation. The Trust has done so.
Not all cases referred to HSIB are baby deaths, and that is also true in east Kent. The criteria for referral includes babies who have received therapeutic hypothermia therapy (cooling), which is an evidence-based treatment that has been shown to have good outcomes for babies exhibiting signs of the clinical syndrome HIE.
According to 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.
It was previously revealed that a critical 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.
Making change
The trust has now put in place the new measures. A statement from the trust says: “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 have made significant changes to our maternity service in recent years to improve the care of women and their families. We are treating the recently raised concerns about the safety of the service with the utmost seriousness and urgency. Leading maternity experts have already started work with us to help us identify further changes we need to make.
“We have set up a Board sub-committee, chaired by an external senior clinician, to review the actions we have taken since we commissioned an independent review into our service in 2015 and ensure we are complying with national safety standards.
We are also commissioning an external review of the data available on our maternity services today, and how it compares with services across the country.”
The trust has implemented a number of changes in maternity services since 2016, including:
- Adding more consultants and senior clinician oversight of births at our hospitals
- Investing in more maternity and neonatal equipment
- Putting a comprehensive training programme in place for all maternity staff on identifying and safely supporting difficult births
- Revising the policy for recruiting and supervising temporary and junior doctors
- Implementing a more comprehensive way of monitoring babies’ health during labour.
A spokesperson said: “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 work with us to make rapid and sustainable improvements to our service.
If you have been under the care of East Kent Hospitals’ maternity service in the past and have concerns about your care, you can contact 01233 651900. This phone line is open 9am to 4pm this week. Your call will initially be answered by the patient advice service.
