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 email@example.com
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.