Dozens of babies died or were injured by poor maternity care, inquiry finds

Medical experts reviewed an 11-year period from 2009 at two hospitals in Margate and Ashford
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Dozens of babies died or were left brain damaged by poor care at one of England’s largest NHS trusts, an inquiry has found.

In an email to staff last month, chief executive of the East Kent Hospitals University NHS Foundation Trust, Tracey Fletcher, said the report would make "harrowing" reading and have a "profound" impact on families and colleagues.

But what did the inquiry find and what has the NHS said?

Here’s what you need to know.

The review examined the circumstances of maternity deaths at both the Queen Elizabeth the Queen Mother Hospital (QEQM) and the William Harvey (Photo: Ben Stansall/AFP via Getty Images)The review examined the circumstances of maternity deaths at both the Queen Elizabeth the Queen Mother Hospital (QEQM) and the William Harvey (Photo: Ben Stansall/AFP via Getty Images)
The review examined the circumstances of maternity deaths at both the Queen Elizabeth the Queen Mother Hospital (QEQM) and the William Harvey (Photo: Ben Stansall/AFP via Getty Images)

What did the inquiry find?

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The medical experts reviewed an 11-year period from 2009 at two hospitals in Margate and Ashford. The review examined the circumstances of maternity deaths at both the Queen Elizabeth the Queen Mother Hospital (QEQM) and the William Harvey.

Dr Bill Kirkup, chairman of the independent inquiry into maternity at East Kent Hospitals University NHS Foundation Trust, said his panel had heard “harrowing” accounts from families receiving “suboptimal” care, with mothers ignored by staff and shut out from their own care.

The report said: “An overriding theme, raised us with 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 inquiry found that of 202 cases reviewed by the experts, the outcome could have been different in 97 cases.

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In 69 of these 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 have had a different outcome if nationally recognised standards of care had been provided.

When looking at 33 of these 45 cases, the outcome would reasonably expected to have been different, while in a further 12 cases it might have been different.

Meanwhile, in 17 cases of brain damage, 12 (72% of 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.

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In nearly half of all cases examined by the panel, good care could have led to a different outcome for the families.

A series of failings emerged during the inquest of Harry Richford, who died seven days after being born in 2017. The hearing in January 2020 found Harry’s death at The Queen Elizabeth the Queen Mother Hospital (QEQM) in Margate was "wholly avoidable".

The trust was fined £733,000 for failing to provide safe care and treatment for him and his mother Sarah Richford. The Richfords have long campaigned for answers after saying their concerns were repeatedly pushed aside by hospital managers.

The trust has apologised for Harry’s death, which it initially said was "expected".

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Birte Harlev-Lam, Executive Director Midwife at the Royal College of Midwives, said: “Every woman should feel that they are properly supported, cared for and listened to by maternity staff throughout pregnancy, labour, birth and the postnatal period. As this report points out, too often this was not the case at East Kent Hospitals NHS Trust, and that is something the RCM deeply regrets.

"What the women and families have been through at East Kent, and that tragedy has been made so much worse by attempts at the highest levels within the Trust to cover up the failings. The culture this created left staff frightened to raise concerns, which compounded the problems yet further.

“As Dr Kirkup’s report points out, the route to improved maternity services would be fatally undermined if individuals were deterred from reporting concerns. The RCM has a long and proud history of supporting those who raise concerns, including whistle blowers. Earlier this year we published updated guidance to support midwives and maternity support workers (MSWs) to do just that.

"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.”

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