An investigation by the Healthcare Safety Investigation Branch has found safety concerns at East Kent Hospitals Trust following a number of preventable baby deaths, including that of one week old Harry Richford, and prompted the sending in of an independent clinical support team to oversee the care being delivered by the trust and an independent review by NHS England.
A BBC 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.
It was also 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.
Concerns raised in the HSIB include the availability of skilled staff, particularly out of hours, access to neonatal resuscitation equipment, the speed with which patient concerns are escalated up to senior clinicians and obstetricians, along with failings in leadership and governance.
The independent clinical support team under England’s chief midwifery officer, Jacqueline Dunkley-Bent, has now been sent in to the hospital trust. The team includes a director of midwifery services from a CQC-rated outstanding Trust, two consultant obstetricians and consultant paediatrician and neonatologist.
In a ministerial statement Parliamentary Under Secretary of State Patient Safety Nadine Dorries said the HSIB had started 25 maternity investigations at the Trust since July 2018, of which 16 have been completed. The investigation raised the concerns, including the failings in leadership and governance.
The government has also received a report from the Care Quality Commission and an update from NHS Improvement and NHS England.
In her statement Mrs Dorries said: “The most important thing when having a baby is that you expect to receive the safest possible care. When things go wrong that lead to harm, it is devastating for all concerned. Therefore, I would like to express my deepest and heartfelt sympathies for the patients and families of those affected.
“The key partners within the health system continue to work with the trust to identify the problems in maternity services and to ensure that swift remedial and appropriate action is taken. We all want and need to know that the care delivered is of the highest standard we would wish for ourselves and for our families.”
Mrs Dorries said some immediate actions have been taken including sending in the independent clinical support team.
She said: “The independent team is working with Trust staff to deliver immediate improvements to care and to put in place robust and comprehensive processes to support improvement in standards over the long term. This input will also support East Kent to meet the ten essential safety actions set by NHS Resolution’s maternity incentive scheme.
“From the findings provided to me it is clear that the challenges at East Kent point to a range of issues including having the right staff with the right skills in the right place, effective multi-disciplinary working, clear collaborative working between midwives and doctors, good communication and effective leadership support. But it would be wrong to speculate that there is one single cause.”
The Regional Medical Director and Regional Chief Nurse are also providing support to the Trust and the Regional Chief Nurse is providing support to the Director of Nursing and Head of Midwifery to put maternity improvement plans in place. They will also review the effectiveness of clinical governance and executive leadership support.
The Care Quality Commission carried out an unannounced inspection of East Kent Hospitals University NHS Foundation Trust’s maternity service at Margate’s QEQM and the William Harvey at Ashford between January 22 and February 5.
A meeting with the Trust, Care Quality Commission and key health system partners is scheduled for February 21 to consider and any further interventions required.
Mrs Dorries added: “It is critical that we continue to strive to make maternity care the safest it can be and to ensure that we build a learning culture in the NHS as set out in the NHS Patient Safety Strategy. This requires leadership at all levels. This is why I have sought and had assurance from each part of the health and care system that they will continue to work with clinical and executive teams at East Kent Hospitals to make improvements to maternity and neonatal services across all sites operated by the Trust.
“Once more, I would like to express my deepest sympathies for the patients and families of those affected.”
Need for reassurance
County councillor Karen Constantine says any inquiry must have a wide remit. She added: “I have raised the need for a public inquiry into maternity services at EKHFT and at QEQM at the Kent HOSC committee. I hope that this HSIB inquiry will provide the detailed insight into what has gone wrong and how to remedy clinical practice to ensure full safety for women and their babies.
“All our thoughts are with the families of those that have suffered loss. However we also need reassurance for those women currently using the maternity services as there is growing concern. I’d like to know if EKHFT use the acuity tool Brightrightplus, which can really help to obtain safety. It is used successfully elsewhere in the country.
“Ultimately we know our midwives and others are working hard, often with regular unpaid ‘overtime’ in order to give the best service they can. Our Government now need to play their part in ensuring there are sufficient midwives in training, that more is done to both recruit and retain workers in a job which whilst often very rewarding, is also extremely demanding. The Government must own the fact, that in the past 10 years, the removal of the bursaries for midwives has caused a critical shortage. This is impacting safety.
“The inquiry needs to be wider than the current remit to ascertain if there are systemic safety failings across the trust.
In addition the Trust should stop all reorganisation work and concentrate on getting the basics right now, alleviating staffing issues and worry for the public. My fear is this inquiry won’t go far enough, fast enough and will be used as an excuse to accelerate yet more change. ”
A spokesman for East Kent Hospitals said: “We know that we have not always provided the standard of care for every woman and baby that they expected and deserved, and wholeheartedly apologise to every one of those families we have let down.
“We are taking all necessary steps to provide safe care and we are treating the recently raised concerns about the safety of our service with the utmost seriousness and urgency.
“This includes making use of support from leading maternity experts, who have already identified further improvements that we will make.
“We recognise that the change needed in our maternity service has not taken place quickly enough, and we are doing everything we can to improve our culture so that we become an organisation which is constantly learning and improving.
“As part of this we continue to work with our regulators in an open and transparent way.
“Our externally-chaired Board sub-committee will review the actions we have taken since we commissioned an independent review into our service in 2015, ensuring we are complying with national safety standards and are implementing the Coroner’s recommendations fully and swiftly.
“Around 7,000 women give birth under our care each year, and one death that could be prevented is one too many. We will not rest until we are delivering an outstanding maternity service that has the full confidence of all families in east Kent.
“We welcome the NHS-commissioned review and will work closely with the independent team to make improvements for families giving birth in east Kent.”