A report due to be published on September 21 from an independent investigation launched in February 2020 in response to a concerning number of avoidable baby deaths at East Kent Hospitals Trust has been postponed.
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.
The 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.
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, thought to be as many as 200, have come forward over the preventable deaths of their babies.
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 was appointed to lead the Independent Investigation. He has previously led a number of independent investigations, including into Morecambe Bay maternity services.
The investigation examined 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.
Report publication delay
The publication of the report has been delayed until October because next Wednesday, when it was expected to be released with a statement made to Parliament, has been set aside for MPs to take an oath of allegiance to King Charles III.
An email to families involved in the investigation says: “Accordingly, there will be no other Parliamentary business on that day. This means that we can no longer have the Report published in Parliament and that Parliament will not focus on the Report and highlight what it says. Nor could there be any response from the Government in Parliament that day.
“As a result, I am sorry to inform you that we are not able to proceed with the disclosure of the report and its publication on the morning of 21 September.
“Everyone, including NHS England and the Department of Health & Social Care, has felt that it would be right to follow through on the plans which we had made and which had been notified to families. The reason for the change of date is simply that Parliament will no longer be conducting business on 21 September.”
The email says the revised date will be in October, after the return of Parliament and the resumption of normal Parliamentary business.
It adds: “We don’t underestimate the impact that postponing the report at such a late stage (a week before expected publication) will have on all the families involved in the investigation. We are so sorry if this news causes additional emotional distress at an already difficult time for you and your family.”
Baby Harry’s grandad Derek Richford says families want the report publication as soon as possible and are calling on local MPs to make sure this doesn’t run into November.
North Thanet MP Sir Roger Gale, who supported the family after baby Harry’s death, has been contacted for comment.
County Councillor Karen Constantine said: “I’m dismayed that the report is being delayed. I note that a new publication date has yet to be set, that should have happened as a minimum.
“Not only will those involved in the enquiry remain in a state of anxiety, as they anticipate the publication, but staff too, will be anticipating the report and may be anxious about it.
“It’s entirely unsatisfactory that so many people are required to wait. Especially with only a vague indication that it will be released in October.”
East Kent Hospitals report
A report to East Kent Hospitals board members says moves have been made to improve maternity services and include the recruitment of an extra 38 midwives this month.
The report on September 1 added: “In addition, we have revised our training for both midwives and medical staff caring for our mothers and babies, to incorporate a 5-day, fully inclusive, mandatory program.”
However, the board report also shows that between April and June 2022, 14 Serious Incidents were declared. 9 maternity clinical care SIs occurred at WHH where 992 babies were delivered, 7 at QEQM where 604 were delivered and 1 in community. Five incidents have been referred to the Healthcare Safety Investigation Branch who are undertaking investigations.