East Kent Hospitals Trust to put action plan in place following harrowing maternity death review findings

Maternity services

Board members of East Kent Hospitals Trust (EKHUFT) will discuss a three year ‘transformation’ plan and an apology letter to the public in response to the damning  publication of an independent report into maternity failings at QEQM and William Harvey Hospitals which found 45 baby deaths could have been avoided.

The report, led by Dr Bill Kirkup and published in October, reviewed the circumstances of maternity deaths at the East Kent Hospitals Trust sites in between 2009 and 2020 in response to a concerning number of avoidable baby deaths.

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. The coroner said there were 7 gross failings that amounted to neglect.

In 2021 East Kent Hospitals Trust was fined a total of £761,170 – inclusive of costs – for failing to discharge its duty to provide safe care and treatment, resulting in avoidable harm with the death of seven day old Harry Richford and sub standard care of his mum Sarah at QEQM Hospital in  2017.

Care Quality Commission inspection

Last month an unannounced Care Quality Commission inspection also raised concerns. These were mainly focused on the William Harvey Hospital and processes for fetal monitoring and escalation and slow maternity triage. Fire safety issues were raised for at the Queen Elizabeth, the Queen Mother Hospital in Margate.

Action plan

The Hospital Trust board will be discussing its plan for improvements to tackle failures including a lack of compassion and failure to listen to women and denial at board level.

Actions will include an independent review of the board, a pilot ‘Calls for concern’ scheme to support patients of any age, their families and carers, to raise concerns if a patient’s health condition is getting worse or not improving as well as expected and a pilot ‘Civility Saves Lives’ in maternity, a programme to eliminate rudeness and incivility, which has been shown to have a positive impact on patient care.

Last March the Trust appointed a full-time Freedom to Speak Up Guardian for maternity, dedicated to listening to and supporting staff to raise concerns.

There will be more staff training and forums and a Reading the Signals Oversight Group which will include representatives from patients and families as well as the Trust’s Council of Governors.

The Trusts says there will be much more patient involvement and it will establish and implement a process for case reviews for families where required.

In Board papers it says of the case reviews: “We have established an Independent Case Review process to respond to families who have concerns about maternity or neonatal care they received from the Trust.

“Families will be offered the opportunity to meet with or speak to experts independent of the Trust, regardless of whether their care had previously been reviewed or investigated by the Trust.

“To date 29 requests have been received, 11 of these have already been agreed as full case reviews, and they will start in February.

“The terms of reference of the Independent Review provide for the opportunity for families who have taken part in the investigation to receive feedback directly from Dr Kirkup and the investigation Panel. These meetings started late 2022. Following these meetings the families will be provided with Disclosure Letters setting out the key aspects of the findings of their individual case.”

Disclosure letters will be made available from mid-February onwards.

Apology letter

Board members will also agree to the public letter of apology. The draft letter says that the report found: “women, babies and their families had suffered significant harm because of poor care in our maternity and new-born services, between 2009 and 2020. The report also found that clinical care was not good enough and that we did not listen to women, their families and indeed at times, our own staff.

The experience those families endured was unacceptably and distressingly poor, and admits: “It also found at least eight opportunities where the Trust Board and other senior managers could and should have acted to tackle these problems effectively. This was simply not good enough.”

Acknowledging the findings that of the 202 cases that agreed to be assessed by the panel, the outcome for babies, mothers and families could have been different in 97 cases, and the outcome could have been different in 45 of the 65 baby deaths, if the right standard of care had been given, The Trust Board says it is: “ determined to use the lessons within it to put things right.”

‘Sexual Offences’ locum

The board will also discuss the employment of disgraced children’s intensive care doctor Dr Salman Siddiqi  who was arrested by Kent Police after a call from a ‘silent hunter’ who said he had arranged to meet the doctor at his lodgings by the QEQM Hospital site under the guise of a 14-year-old boy.

He was arrested and pleaded guilty to offences under the Sexual Offences Act. The Locum registrar in paediatrics was employed through an NHS Framework agency by the Trust between January 2021 and January 2023 on an ad hoc basis to cover rota gaps for on call day or night duties at both WHH and the QEQM sites, a total of 111 shifts.

The Board papers say: “All appropriate action has been taken since his arrest and the doctor was referred to the General Medical Council. Police and safeguarding investigations are not yet complete.

“We have undertaken a review of his employment at the Trust. While the findings of this review do not suggest that there were omissions or failures within the Trust’s processes that would have directly predicted or prevented this criminal offence, there is undoubtedly further learning and actions recommended around the employment of temporary workers.

“Since the doctor was first employed we have introduced and embedded a Temporary workforce team that now hold the responsibility for ensuring all checks are in place.”

The Board meeting takes place on Thursday (February 9).

The apology letter to the public is due to be published the following week.

Help us to continue bringing you Thanet news with a donation towards our running costs https://www.paypal.com/donate/?hosted_button_id=YF7BH2EF4UG2N


  1. Be a good idea for the board members to individually sign this document, in public, with TV cameras present. They all should hang thier heads in shame..

  2. It’s a bit late. They’ve known failings for years. The same management should not be left if place. Not only is this about the tragic death of so many babies but also bad outcomes for 1000s of couples and mothers that suffered at the hands of this department. Children whose lives were altered. I find it shocking that they still haven’t investigated that side.

    Only preventable deaths.

    They should also be looking at the other preventable outcomes.

  3. Haven’t we heard all this for years now? Making changes, listening, bringing in another ‘safe pair of hands’ to run things & then the inspectors come in & find very little has changed & it is as we all said just lip service, with a new coat of paint.

  4. Fining hospitals is absolutely ludicrous. All it can do is to lower the quality of patient care still further. Would be better to shame management by widely publicising findings, sack (or prosecute?) anybody directly at fault and then insert a team of relevant, accountable professionals to oversee the running of failing departments for as long as necessary. Ah, but the last bit would cost money as opposed to extracting it from an ailing organisation so never mind that direct intervention is what is actually required.

Comments are closed.