East Kent Hospitals, which runs sites including the QEQM in Margate, is one of 14 trusts that will be in a rapid, national investigation of maternity and newborn baby care across England.
It is one of three trusts chosen where previous investigations have taken place and learnings from these will be incorporated in the new investigation.
The investigation will deliver one clear set of national recommendations to achieve consistently high-quality, safe maternity and neonatal care.
Baroness Amos chairs the investigation which will put families at the heart of the work. Affected families were asked to provide input to the draft terms of reference of the investigation.
The Terms of Reference have been developed to focus on understanding the experiences of affected women and families, identifying lessons learned and driving the improvements needed to ensure high quality and safe maternity and neonatal care across England.
The investigation was announced in June by Health and Social Care Secretary Wes Streeting who said the government had inherited systemic problems in maternity and neonatal care dating back over 15 years.
It comes alongside a package of immediate actions to improve care, including greater intervention by the Secretary of State and NHS Chief Executive to hold failing trusts to account.
‘Extraordinary courage’
Health and Social Care Secretary Wes Streeting said: “Bereaved families have shown extraordinary courage in coming forward to help inform this rapid national investigation alongside Baroness Amos.
“What they have experienced is devastating, and their strength will help protect other families from enduring what they have been through.
“I know that NHS maternity and neonatal workers want the best for these mothers and babies, and that the vast majority of births are safe and without incident, but I cannot turn a blind eye to failures in the system.
“Every single preventable tragedy is one too many. Harmed and bereaved families will be right at the heart of this investigation to ensure no-one has to suffer like this again.”
The investigation will urgently look at a range of services across the entire maternity system, following independent reviews across multiple trusts that have revealed a pattern of similar failings: women’s voices ignored, safety concerns overlooked, and poor leadership creating toxic cultures.
The Health and Social Care Secretary and Baroness Amos have agreed the terms of reference of the independent investigation, which will include understanding the lived experiences of families, reviewing the quality and safety of services, identifying the drivers and impact of inequalities and identifying barriers to making improvements.
Following its conclusion, she will deliver one clear set of national recommendation to achieve consistently high-quality, safe maternity and neonatal care, with interim recommendations delivered in December 2025.
‘Drive improvements’
Baroness Valerie Amos said: “It is vital that the voices of mothers and families are at the heart of this investigation from the very beginning.
“Their experiences – including those of fathers and non-birthing partners – will guide our work and shape the national recommendations we will publish. We will pay particular attention to the inequalities faced by Black and Asian women and by families from marginalised groups, whose voices have too often been overlooked.
“Our aims are to ensure the lived experiences of affected families are fully heard, to conduct and publish 14 local investigations of maternity and neonatal services, and to develop recommendations informed by these that will drive improvements across maternity and neonatal services nationwide.”
The 14 trusts have been chosen on factors including data and metrics, such as the CQC maternity patient survey and MBRRACE-UK perinatal mortality rates.
The investigation will run alongside a National Maternity and Neonatal Taskforce – set up and chaired by the Health and Social Care Secretary and made up of a panel of experts and families.
It will begin its work this summer and produce an initial set of national recommendations by December.
Significant improvements
East Kent Hospitals said: “We welcome the opportunity to take part in this important review and to share our learning from our journey to improve maternity services in east Kent.
“Our staff have worked hard alongside families to make significant improvements to our maternity and neonatal services. We are committed to continuing this journey to provide the highest standard of care for our communities.”
The maternity services at William Harvey Hospital, Ashford and Queen Elizabeth The Queen Mother Hospital, Margate were last rated ‘good’ by the Care Quality Commission (CQC).
The CQC inspected the service in December 2024 and found the Trust had made ‘significant improvements’ since its last inspection in 2023.
It rated both units as ‘good’ for being caring, effective, responsive and well-led.
The inspections were carried out to follow up on the urgent conditions CQC imposed upon the trust that required it to take action to ensure significant improvements were made to safety, leadership, culture, the environment and staffing levels. CQC found significant improvements had been made.
Kirkup Review
The improvements followed previous failings in care that were highlighted in 2022 in the publication of an independent report which found 45 baby deaths could have been avoided.
NHS England and NHS Improvement commissioned Dr Bill Kirkup to carry out that independent review into the circumstances of the maternity deaths at the East Kent Hospitals Trust sites 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.
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.
Some 200 families came forward to the Kirkup review over the preventable deaths of their babies.
