Staff at East Kent Hospitals Trust, and mums-to-be who are using the maternity service, are being warned that an independent report into unavoidable baby deaths at the Trust is expected to be ‘critical’ and ‘harrowing.’
The report was launched in February 2020 in response to a concerning number of avoidable baby deaths at the Trust’s QEQM and William Harvey hospitals. It had been due for publication in September but this was postponed due to the death of Queen Elizabeth II. It is now due to be published on October 19.
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.
Baby Harry’s grandad Derek Richford says families want the report publication as soon as possible.
Letters have been sent to expectant mums by the Trust in a bid to allay concerns that might arise from the report.
In the letter it says: “As a member of our local community you may be aware that our maternity services have been the subject for investigation by an independent team of experts since 2020. This team has been examining care provided by our maternity and neonatal services (since 2009).
“While this independent investigation has been underway we have been working hard on improvements to the care we offer women and families using our services. However, we know there is more for us to do.
“We expect the investigation report will be published on Wednesday 19 October and anticipate it will be critical of the care we have provided.”
The letter outlines support for mums-to-be including a dedicated phoneline to discuss report worries, open from October 15, on 616162.
Sky News today (October 17) reports that staff at the Trust have also been sent an email warning them that the report is expected to be “harrowing.”
Mums-to-be and families with concerns can contact the trust on ekhuft.maternityinvestigationenquiries@nhs.net
A report to East Kent Hospitals board members last month says moves have been made to improve maternity services and include the recruitment of an extra 38 midwives in September.
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.
Keep clapping
I’ll look forward to reading this
I’ve never had cause to experience the establishment’s maternity service. However, during the thirty or so years I’ve lived here the few experiences I’ve had of its services have all been negative.
My daughter was born there in 2003 and the care that we both got was non existent. The ward was dirty and it seemed that there was no nursing staff around. No-one had bothered to record that we were there (so we did not exist???). After my caesarian I needed to see a nurse so rang the alarm but no-one came. I rang for hours and hours. Eventually a nurse came from the operating theatre, fed up with me ringing. That was 7 hours later. I was there a week and the nursing staff were not in evidence.
I wrote a letter of complaint to the matron and wass promised that something would be done. OBVIOUSLY NOT!
They should have known they had problems in 2003 but they could not have cared less.
What is needed, as a minimum, is:-
1. A Consultant Obstetrician with responsibility to work with the local Supervisor of Midwives, to ensure that obstetricians and midwives work in partnership caring for their patients. The same Consultant and Midwifery Manager should manage the births audit together and should systematically review every untoward incident reported.
2. 24/7 Consultant Obstetrician rostered cover of the Central Delivery Suite and available for immediate consultation when any complications arise in the Midwife Managed Delivery Suite.
3. Changes to Midwifery training to move away from the current culture that promotes only non interventional delivery and views any medical involvement as ‘failure’, which results in higher risk pregnancies not being reviewed in advance by a medical specialist and birthing complications left too late before calling for medical assistance.
You forgot the most important thing-NHS Trusts & the Bosses of them listening to patients, listening to staff & listening to the recommendations of inspections/reviews into them & acting upon them.
Not employing bullying tactics to staff who whistle-blow or even ‘dare’ to question what is happening, not putting up blocks to patients & their relatives, not lying & what must be stopped is this sticking up for other medical professionals not reporting bad behaviour nonsense, that allowed the likes of Rodney Ledward & Ian Paterson to get away with it for years/decades & as we have heard in the ongoing Lucy Letby trial a doctor not reporting her after highly suspect behaviour & very serious observations he made/her story, as a baby was in a very serious condition.
Absolutely. We used to call it a ‘no blame’ culture. Staff were encouraged to report their own errors and any mistakes they observed and the Trust Board guaranteed them protection from disciplinary action if they did report. They also knew that cover up of their mistakes, or those observed of others, would not be tolerated.
Any idea what happened to Rodney Ledward Steve? My wife, as was then, walked out of one of his surgeries because of the off hand way he was treating her, and never went back! He disappeared soon after, and I think there may have been a report he popped up in Ireland where I think he had property!
Guess who the Tory government Secretary of State for the NHS was for 6 years, yup, Jeremy Hunt the current Chancellor! He has just surrounded himself with a “new economic advisory council” according to my newspaper, one of them is a “chief economist at US Hedge Fund Element Capital”, and another is “the chief investment officer for asset management company PGIM Wadhwani”. So thats all good then, the country’s economy is now being advised by Hedge Fund managers, who will look after the weak, the sick, the infirm, the frail, and the poor, and the elderly, as if! Watch out for more welfare benefit, and efficiency cuts, as if cutting staff can ever make a public service “efficient”!
Just to give some balance to this. I had a baby at QEQM in 2021 and the staff were amazing. I felt listened to, me and my baby were well cared for, the staff were always reassuring, available and brilliant at talking through what was happening and what my options were. I felt in very safe hands.
I just had a baby in July this year and I’ve got to say next to having my daughter in 2015 these two were the single most worst experiences of my life. My daughter was born not breathing in 2015 and would have died if it wasn’t for me. It really doesn’t surprise me so many babies have died under their watch, all still fresh in my mind and although my baby boy was born healthy I am now mentally scarred from the lack of compassion and care from the staff, left in pain for 2 days with nothing but paracetamol and no one listening to me telling them I know my own body. Now I have to deal with this trauma for the rest of my life.