East Kent Hospitals Maternity Scandal

The Healthcare Safety Investigation Branch (HSIB) has been investigating maternity care provided at East Kent Hospitals University NHS Foundation Trust since July 2018.  There have been a number of babies that have died.  The hospitals under investigation are William Harvey Hospital in Ashford and The Queen Elizabeth The Queen Mother Hospital in Margate.

The failings first came to light during the inquest of Harry Richford, who sadly died seven days after he was born at The Queen Elizabeth The Queen Mother Hospital in Margate in November 2017.  There were complications with his birth and the aftercare provided.  A coroner later decided that his death was ‘wholly avoidable’.

Subsequently, an independent report from the Department of Health and Social Care looked into 24 separate cases since July 2018, including the tragic deaths of three babies and two mothers.  16 of these cases have been investigated and a further eight are still being investigated.

The report shows that there are recurring safety risks, and that despite the HSIB repeatedly raising these concerns with the Trust, investigators continued to see the same themes arising.  In August 2019, the HSIB asked the Trust to self-refer to their Clinical Commissioning Group and the Care Quality Commission.

The report found a range of factors contributing to the problems with the Trust’s provision of maternity care.  These include:

• Concerns over the lack of availability of staff with suitable skills in reading and interpreting CTG (cardiotocograph, the machine used to monitor the foetal heart rate) results

• A reluctance of midwifery staff to escalate concerns to obstetric and neonatal colleagues in complicated births

• Issues with delivering timely and effective resuscitation of newborns due to issues with the location of equipment and a lack of appropriately trained staff

• Cases where the condition of mothers and babies deteriorated because staff had failed to recognise the signs and symptoms that indicate deterioration

The report found that the Trust was ‘inappropriately slow given the evidence of ongoing patient safety risks and the safety recommendations made’.  An independent inquiry is due to begin in April 2020 to investigate the deaths further.

Sadly, the report states that these issues are not unique to Kent and have been seen throughout England.  There has been recent press coverage of the issues with maternity care in Shrewsbury and Telford Hospital NHS Trust and the 2016 National Maternity Review highlighted widespread problems across the country with quality and safety, a failure to learn from mistakes, underreporting of safety incidents and missed opportunities to prevent stillbirth even when mothers had expressed their own concerns.

It is devastating to read about the avoidable deaths and injuries caused to babies and mothers as an outsider, so I can only imagine what a nightmare it must be to live through.  It is clear from all the reports and investigations into various NHS Trusts that there are deep rooted issues with maternity care throughout England.  More must be done to learn lessons from these tragic outcomes and to prevent any other family having to go through the same trauma and heartbreak.

These failures can lead to outcomes that have a devastating, life-changing impact on the families involved.  Those families deserve answers and urgent changes to hospital culture and maternity services must be made so that no more families suffer.  I would hope for changes to be made in making sure equipment was easily available and that it was ensured that there were enough specialist trained staff to assist.  I would hope that more awareness is raised of early signs of deterioration and a culture change to allow staff to feel more comfortable in escalating their concerns.

If you think you have been affected by substandard maternity treatment you should seek the opinion of an expert lawyer as soon as possible.  You may be able to bring a claim for medical negligence against the hospital that treated you and your baby during your pregnancy and labour.  We understand the devastating impact these events have on mothers and their families and we are keen to get families the answers that they deserve.