Trust to create maternity services ‘improvement programme’ after just 2 of 23 safety review recommendations implemented

Maternity services

A report to members of the East Kent Hospitals Trust says just two of 23 recommendations for maternity services at QEQM in Margate and William Harvey Hospital in Ashford have been fully implemented.

The recommendations were made in a report by the Royal College of Obstetricians and Gynaecologists in 2016.

The RCOG review highlighted 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.

Out of the 23 recommendations made in the review the Trust has fully implemented two and partially implemented 11.

It now says an improvement programme is being drawn up for maternity services that will cover the RCOG recommendations as well as those made by the Care Quality Commission following a rating of Requires Improvement after inspections in January and February.

Two Requirement Notices were issued relating  to improvements needed to governance and provision of the safe care and treatment in its the maternity services.

The CQC inspections took place after concerns were raised about the safety of maternity services at the Trust, including the inquest this January into the death of baby Harry Richford, who died at Queen Elizabeth The Queen Mother Hospital in 2017, and a number of families then coming forward over the ‘preventable’ deaths of their babies.

The troubled maternity service has been subject to a report by the Health and Safety Investigation Branch (HSIB) which found recurrent patient safety risks at the Trust maternity sites at QEQM Margate and William Harvey Hospital and is subject to a review commissioned by NHS England and NHS Improvement into the maternity and neonatal services.  The investigation is being led by Dr Bill Kirkup and is expected to cover the period since 2009.  Dr Kirkup expects to report in 2021. 

A report of the maternity Learning and Review committee, published in Trust Board papers this month, says: “Of 23 recommendations the LRC accepted that two were met, 11 were partially met, and for 10 there was either no evidence of delivering the recommendation, or available evidence suggested it had not been delivered.”

The report also noted the Trust has seen a decline in stillbirths but a rise in neonatal deaths from 1.69 per 1,000 in 2018 to 2.97 per 1000 in 2019.

The report says: “There is speculation that more babies are being born prematurely nationally and locally, and small changes in the number of babies who die has a significant effect on rates (the number of neonatal deaths that would be average in a year for a hospital delivering 7000 babies is 15).”

It is suggested the Trust commissions a report on neonatal mortality for East Kent and says Imperial College is looking into the trust’s level of neonatal encephalopathy – which affects the brain and nervous system and is often caused by lack of oxygen to the baby during birth – which is higher than average in England.

Recommendations made by the coroner at Harry Richford’s inquest have been, or are in the process of being, implemented.

An increase in maternity staffing has also taken place at both hospital sites “allowing a significant increase in consultant obstetrician presence on the labour ward,” and seeing a rise in senior midwives.

‘Public Inquiry’

County councillor Karen Constantine, who sits on the KCC health scrutiny panel, said she would like to see a public inquiry.

She said: “This is an exceptionally worrying and damning report, significant progress to improve maternity services should have been made. That infant mortality rates have risen from 1.69 per 1,000 births in 2018 to 2.97 in 2019 is tragic. We need a Public inquiry into neonatal mortality in East Kent and QEQM.

“In addition we urgently need the Government to uphold its promise to recruit and train more midwives to deal with the chronic shortage. We can’t just rely on ‘homegrown’ talent we need our midwives from across the world, Brexit is hampering global recruitment.

“The RCM have pointed out there has been a slight increase in the UK of midwives going back onto theNursing and Midwfery Council register, but a significant decline in overseas midwives. This will result in less midwives. Without qualified midwives we cannot deliver babies safely.

“I’d like to see both our local MPs tackle this issue with the same passion they have poured into supporting the controversial air freight hub at Manston and I wonder if they realise that air pollution harms foetuses, increasing the risk of miscarriage, premature birth and low birth weights.

“My thoughts are with those families that have lost babies.”


A spokesman for the Trust said: ““We are determined to provide an excellent standard of care to every mother and child who uses our maternity service, and we will not rest until we, the public and our regulators are confident we are doing so.

“Therefore, as part of our response when concerns were raised about the safety of our maternity services in January this year, we committed to scrutinising robustly what had been done in response to the RCOG report since 2016, and also whether the Trust holds sufficient evidence of completion for each of the 23 recommendations.

“We set up a Board Learning and Review Committee, chaired by an external senior clinician, to oversee this work. This was one element of the Committee’s remit to objectively and comprehensively examine the Trust’s governance of maternity services.

“The findings from the review have been published today.

“Of the 23 recommendations, the review considered that 13 had been met or partially met, but that for 10 of the recommendations, there was insufficient evidence of fully delivering the recommendation.

“All the recommendations from the RCOG report, the CQC report and from elsewhere are being incorporated into a single Integrated Improvement Programme for maternity. The Board will have full oversight of this Programme.”