An independent investigation launched in February 2020 in response to a concerning number of avoidable baby deaths at East Kent Hospitals Trust has progressed to the next stage.
NHS England and NHS Improvement commissioned Dr Bill Kirkup to carry out an independent review into the circumstances of the maternity deaths at QEQM and William Harvey hospitals.
The move came alongside a report by the Health and Safety Investigation Branch (HSIB) which found recurrent patient safety risks at the Trust maternity sites at QEQM and William Harvey Hospital.
Issues with maternity were brought into the spotlight following the death of baby Harry Richford at Margate’s QEQM Hospital in 2017 after a series of errors.
Last year a coroner ruled that Harry’s death had been avoidable. The inquest during January 2020 had heard of the “panic” after Harry was born by emergency Caesarean section during which his heartbeat kept dropping. Harry died seven days after his delivery from a condition caused by a lack of oxygen. An independent report said he might have survived had there not been a delay in resuscitation at his birth that caused irreversible brain damage.
Coroner Christopher Sutton-Mattocks agreed with that conclusion and said Harry and his parents had been ‘failed.’
There was also criticism of the hospital trust which had said Harry’s death was expected, resulting in his parents, Tom and Sarah Richford, from Birchington, having to fight for an inquest.
Since Harry’s inquest a number of families have come forward over the preventable deaths of their babies.
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.
Last year the Care Quality Commission confirmed it was bringing charges against the Trust in connection with Harry’s death. It will be the first case of its kind against a Trust brought under powers the CQC was given in 2015.
The independent review was one of a series of actions to bring in urgent improvements to the service and examine what went wrong and why.
Dr Bill Kirkup (pictured) was appointed to lead the Independent Investigation. He has previously led a number of independent investigations, including into Morecambe Bay maternity services.
The investigation is to examine the management, delivery and outcomes of care provided by the maternity and neonatal services at East Kent University Hospitals NHS Foundation Trust during the period since 2009.
Initially the investigation team was calling for families to get in touch so the panel could look at individual cases where there has been a preventable or avoidable death; a concern that the death may have been preventable or avoidable; a damaging outcome for the baby or mother; or where there was reason to believe the circumstances shed light on how maternity services were provided or managed or how the Trust responded when things went wrong.
Today (March 11) the Terms of Reference for the investigation were published. These outline how the investigation will proceed and the main issues that will be covered.
These are:
- What happened at the time, in individual cases, independently assessed by the investigation.
- In any medical setting, as elsewhere, from time to time, things do go wrong. How, in the individual cases, did the Trust respond and seek to learn lessons?
- How did the Trust respond to signals that there were problems with maternity services more generally, including in external reports?
- The Trust’s engagement with regulators including the CQC. How did the Trust engage with the bodies involved and seek to apply the relevant messages? And what were the actions and responses of the regulators and commissioners?
The investigating panel says it will now concentrate on meeting those families who have been in touch and analysing records.
It will take account of other relevant work including:
- Healthcare Safety Investigation Branch Reviews
- The invited review by the Royal College of Obstetricians and Gynaecologists in 2015/16
- The invited Royal College of Paediatrics and Child Health review in 2015
- Perinatal Mortality Review Tool data and reports
- Intelligence from the CQC/associated reports/recommendations
- Letters and findings from HM Coroners
- Each Baby Counts reviews (the Royal College of Obstetricians and Gynaecologists national quality improvement programme)
A statement from the independent investigation panel says: “We are very grateful to those families who have come forward and confirmed their wish to have their cases considered as part of the investigation.
“The investigation commenced on 23 April 2020 and a number of families came forward at that stage. On the 1st October 2020, as Chair of the Independent Panel, Dr Kirkup issued an invitation for any new families to let us know if they too would like to participate in the investigation.
“As a result, an increased number of families have been included in the work of the investigation and sessions are underway enabling panel members to hear directly from family members. It is already clear that the increased number of cases and the range of circumstances they present will enable the panel to fulfil each part of the Terms of Reference, as now published here.
“The focus is therefore now shifting from receiving new cases to meeting the families who have come forward and to analyse the various records and completing the remaining stages of the investigation.”
The Independent Investigation will aim to complete its Terms of Reference research by Autumn 2022.
Susan Acott, Chief Executive of East Kent Hospitals, said: “We wholeheartedly apologise to those families we could have done things differently for and we are grateful to everyone who has shared their experience of our maternity services.
“We are continuing to support the investigation team and working with the Healthcare Safety Investigation Branch (HSIB) and our partners, we have made improvements to our service, including by increasing staffing levels, launching a continuity of carer home birth team and building a dedicated maternity triage unit.”
Recent changes to East Kent maternity service include:
- increased staffing, including a 24-hour consultant presence at the acute maternity unit at William Harvey Hospital, Ashford
- launching a continuity of carer home birth team to improve outcomes and safety
- building a new, dedicated maternity triage unit at William Harvey Hospital, due to open in March.
