SAFETY FAIL
‘Harrowing’ report reveals 45 babies died needlessly in one of NHS’ worst-ever maternity scandals
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AT LEAST 45 babies died needlessly in one of the NHS’ worst ever maternity scandals, an inquiry revealed today.
Decades of failings across East Kent Hospitals left dozens suffering 'unacceptably poor' care.
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Investigators said 45 baby deaths between 2009 and 2020 across the trust could have been avoided.
Maternity staff at East Kent Hospitals NHS Trust were so “dysfunctional” they were like warring tribes and refused to work together, risking patient safety.
Babies were left seriously hurt as a result of the failings, and mothers were left injured in the latest maternity scandal to hit the NHS.
Releasing a 180-page report in Folkestone today, inquiry chair Dr Bill Kirkup said his panel heard "harrowing" accounts from families who were shown a “shocking” lack of compassion by staff.
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"An overriding theme, raised with us time and time again, is the failure of the trust's staff to take notice of women when they raised concerns, when they questioned their care, and when they challenged the decisions that were made about their care," the report said.
One inspector said the hospitals’ workplace culture was 'the worst I’ve ever seen'.
Bosses ignored eight stark warnings and reports since 2010 and still had not improved by 2020.
The latest report, commissioned by ministers in 2020, spoke to 202 families who suffered death or injury in the units - and ruled 97 could have been avoided.
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It said 45 out of 65 baby deaths were preventable, along with 12 brain damage cases 23 injuries to or deaths of mums and 17 other incidents.
Dr Bill Kirkup, former associate chief medical officer for England, led the inquiry after chairing a similar one in Morecambe Bay in 2015.
At a press conference this morning he branded the Kent report “deplorable” and “harrowing”.
He said: “What troubles me the most is the attitudes and behaviour that dismissed women who had complaints and questions.
“Clinical errors happen everywhere and I wouldn’t want to discourage people from reporting them.
“But when staff deny the truth and refuse to tell people the information they deserve to know - and the same things happen over and over - I find that shocking.”
Without urgent action, Dr Kirkup said he fears investigators will be forced to examine similar cases at other NHS trusts.
Dr Kirkup's review found that:
- Of 202 families who came forward, the outcome could have been different in 97 cases, if services had been up to scratch
- In 69 of the 97 cases, it is predicted the outcome should reasonably have been different - and could have been different in a further 28 cases
- Of the 65 baby deaths examined, 45 could've lived or might have survived, if they had been given nationally recognised standards of care
- When looking at 33 of these 45 cases, the outcome would reasonably be expected to have been different, while in a further 12 cases it might have been different
- Meanwhile, in 17 cases of brain damage, 12 cases could have had a different outcome if good care had been given, of which nine should reasonably have been expected to have had a different outcome
- In nearly half of all cases examined by the panel, good care could have led to a different outcome for the families
- When it came to injuries to mothers, and the deaths of mothers, the outcome could have been different in 23 out of 32 cases
- In 15 of these 23 cases, the outcome would reasonably have been expected to be different.
The inquiry followed a campaign by the family of baby Harry Richford, who died at just seven days old at Queen Elizabeth the Queen Mother Hospital in Margate in 2017.
Parents Sarah and Tom said the birth of their son was “botched” by staff and a coroner ruled his death was avoidable - highlighting more than a dozen areas of concern, including failings in the way an "inexperienced" doctor carried out the delivery, as well as delays in resuscitating him.
The trust was fined £733,000 last year for failures in Harry's care after he suffered brain damage.
Dozens of other families revealed medics were too slow to treat critically ill babies, bungled deliveries and disrespected families.
Dr Kirkup’s review said staff and bosses had tried to hide or shift blame for the failings - but it all came down to toxic rows among their ranks.
Top doctors had “huge egos” and midwives split into cliques that criticised other staff in front of patients.
Bullying was so intense it put patient safety at risk and senior doctors refused to help younger staff or work out of hours.
The report said “staff were disrespectful to women” and showed a “shocking” lack of compassion.
One midwife told a mum whose baby died that it was “God’s will” - and another patient was ignored when she said her pain relief failed and she felt a scalpel cutting her tummy.
Responding to the new report, Danielle Clark, mother to Noah, whose case was investigated, said: “People need to be held accountable.
"Things have got to change. Babies are dying just through bad care and pure neglect.”
Tracey Fletcher, chief executive of the East Kent Hospitals NHS trust, said: “I want to say sorry and apologise unreservedly for the harm and suffering that has been experienced by the women and babies who were within our care, together with their families, as described in today’s report.
“We must now learn from and act on this report; for those who have taken part in the investigation, for those who we will care for in the future, and for our local communities. I know that everyone at the trust is committed to doing that.”
Chancellor and former health secretary Jeremy Hunt said: “It’s simply unthinkable that, on top of all the other maternity care scandals we’ve heard about in recent years, another one has been uncovered with 45 baby deaths.”
The eight missed opportunities: How bosses failed to act
- 2010: Internal medical director’s review warns of a rise in cases of brain damage in newborns and raises concerns about staffing and management.
- 2013: Local NHS boards flagged concerns about the number of serious maternity incidents but met “anger and defensiveness” from the hospital trust.
- 2014: The Care Quality Commission rated the hospital trust “inadequate” and the maternity services “requires improvement” - the second lowest grade.
- 2014-15: HR interviewed 110 maternity staff and found bullying and abuse was rife.
- 2015: Head midwife told bosses she noticed the same trends reported in a review that uncovered the deaths of 11 tots and a mum at Morecambe Bay Hospitals in Cumbria.
- 2016: Maternity services criticised as “poor” in a report by the Royal College of Obstetricians and Gynaecologists.
- 2017: Baby Harry Richford died seven days after birth and his family blamed the Margate hospital. They later successfully sued the trust for over £700,000.
- 2018: The Healthcare Safety Investigation Branch said the rate of safety incidents at the hospitals was so high it made the trust an “outlier”.
The latest scandal marks one of the worst to hit NHS maternity services, and comes after the Ockenden report revealed in March that 201 babies and nine mums died because of decades of NHS failings in Shrewsbury and Telford.
Meanwhile, the Morecambe Bay investigation, also led by Dr Kirkup, found in 2015 that a "lethal mix" of failings at almost every level led to the unnecessary deaths of one mum and 11 babies at the maternity unit in Cumbria.
Another inquiry is already under way in Nottingham.
Responding to the report, Birte Harlev-Lam, Executive Director Midwife at the Royal College of Midwives (RCM) said everyone involved in maternity care should be able to stand up for high standards.
"Doing so is how we learn from errors and ensure they are not repeated. All of us - midwives, doctors, regulators and trust management - must work together to fix these toxic cultures that put women and babies at risk," she said.
Anita Jewitt, a medical negligence lawyer at Irwin Mitchell, said: “This report makes for stark reading.
“This should have been a joyous time for these families but, instead, the report lays bare how families were badly let down, with devastating consequences.
“While nothing can make up for what the families have gone through, this needs to be a day which helps lead to decisive and lasting change.
“Too many maternity reviews have highlighted similar issues across the country and it’s crucial that changes are made to prevent more heartache for families in future.”
The East Kent NHS Trust is one of the biggest in England and runs hospitals in Dover, Canterbury, Margate, Ashford and Folkestone.
I just felt I wasn’t listened to. They kept making me feel like I was going insane, I was going crazy, no one was listening to me.
Laura Cooke
Helen Gittos, who lost her daughter Harriet in 2014, has also said she was treated with contempt by the trust.
Another mum, said she felt as though she was blamed for the death of their child.
Kelli Rudolph's daughter Celandine died at five days old at William Harvey Hospital and says she felt as though the family's concerns were dismissed.
Speaking to Sky News this afternoon another family said they had been 'destroyed' after the death of their son.
'NO ONE LISTENED'
Vlado Gavrilescu and Laura Cooke lost their little boy Luci when he was just four weeks old, from tuberculosis.
His parents had become concerned that he was struggling to breathe, but when they took him to hospital, he was sent home without treatment.
Mum Laura, said: "He was very sick to the point where I was staying awake all night watching over him in his cot.
"I just felt I wasn’t listened to. They kept making me feel like I was going insane, I was going crazy, no one was listening to me.”
They took him back to the hospital twice in two weeks, but medics couldn't see how ill he was.
His heartbroken father, Vlado said: "Doctors said everything was OK and was under control and was fine, [they said] he is going to be transferred to a London hospital and after 30 minutes they come and said he had passed away."
Dr Kirkup said the trust deflected and denied problems when families bought them forward, branding it "stark and shocking".
"We owe it to them to listen and take seriously what has happened and address the areas set out," he said.
These areas include teamwork within trusts, professionalism and listening and taking the concerns of women seriously.
FAILINGS
Kim Thomas, the CEO of the Birth Trauma Association said in their experience, there are many more maternity units that share these failings.
He said that it is upsetting to read once again that babies died to were harmed because of poor maternity care.
"Following the 2015 Morecambe Bay report, and the 2022 Ockenden report, this is the third major investigation showing failings in the maternity system.
"The three reports share similar themes: a lack of team working, a failure to listen to parents and a refusal to take responsibility for mistakes.
"Our experience of supporting parents suggests, unfortunately, that there are many more maternity units that share these failings. It is time for an overhaul of maternity care to make sure that outcomes are monitored, and that problems are identified and addressed.
"Compassion should not be an optional extra. Every woman deserves good quality, evidence-based maternity care," he said.
In a statement today, health minister Dr Caroline Johnson said she was 'deeply sorry' to all the families that have suffered and continued to suffer from the tragedies detailed in the review.
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She added: "We are committed to preventing families from going through the same pain in future and are working closely with the NHS to continue improving the quality of care for mothers and babies with support teams for trusts, backed by £127 million to grow the workforce and improve neonatal care.
“We take these findings and recommendations extremely seriously and will review them all in detail ahead of publishing a full response.”
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