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Dozens of babies died needlessly in one of NHS’ worst-ever maternity scandals, harrowing report reveals
19 October 2022, 11:51 | Updated: 19 October 2022, 13:48
At least 45 baby deaths could have been avoided across two Kent hospitals, a review has found.
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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.
"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 report said.
Of 202 cases reviewed by the experts - dating back to 2009 - the outcome could have been different in 97 cases, the inquiry found.
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.
In nearly half of all cases examined by the panel, good care could have led to a different outcome for the families.
Speaking about the issues, Dr Bill Kirkup said: "This is a cruel practice that ends up with families being denied the truth.
"That's a terrible way to treat somebody in the name of protecting your reputation."
He added: "I do recommend a statutory provision for this.
"It would place a legal duty on public bodies to be truthful and not to conceal problems."
The study, which marks the culmination of an independent inquiry into maternity at East Kent Hospitals University NHS Foundation Trust, describes how newborn babies died due to poor care spanning several years.
East Kent runs major hospitals, with its main maternity services at the Queen Elizabeth The Queen Mother Hospital (QEQM) in Margate and the William Harvey Hospital in Ashford.
Health Minister Dr Caroline Johnson said: "I am deeply sorry to all the families that have suffered and continue to suffer from the tragedies detailed in Dr Bill Kirkup’s review.
"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."
The families of babies who received poor care at the trust were the first to read the findings of Dr Kirkup's inquiry.
He said the findings had left families feeling "substantial anger" with the room being filled with "a great deal of emotion".
The family of baby Harry Richford, who died a week after his birth at the QEQM in 2017, have long campaigned for answers after saying their concerns were repeatedly brushed aside by hospital managers.
The trust was fined £733,000 last year for failures in Harry's care after he suffered brain damage.
A previous inquest ruled his death was "wholly avoidable" and found more than a dozen areas of concern, including failings in the way an "inexperienced" doctor carried out the delivery, followed by delays in resuscitating him.
Among them were also the parents of Archie Batten, who died in September 2019 at the QEQM.
A coroner ruled he died of natural causes "contributed to by neglect" and "gross failure".
Chief Executive of the East Kent Hospitals University NHS Foundation Trust Tracey Fletcher said in a statement: "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.
"These families came to us expecting that we would care for them safely, and we failed them.
"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.
"In the last few years we have worked hard to improve our services and have invested to increase the numbers of midwives and doctors, in staff training, and in listening to and acting on feedback from the people who receive our care.
"While we have made progress, we know there is more for us to do and we absolutely accept that.
"Now that we have received the report, we will read it in full and the Board will use its recommendations to continue to make improvements so that we are providing the safe, high-quality care our patients expect and deserve.
"I want every family – whether they contributed to the investigation or not – to know I am here to listen to them, to learn and to lead our Trust in acting on this report."