Kirkup Report: Babies might have survived if they had received better care at East Kent NHS Trust

An independent review into maternity failings at East Kent NHS Hospitals Trust has found that 45 babies might have survived if they had received better care.

Chaired by Dr Bill Kirkup CBE and published last week, the review focused on an 11-year period from 2009 at two hospitals within the trust – Queen Elizabeth The Queen Mother Hospital, Margate and William Harvey Hospital, Ashford.

Medical experts uncovered a “clear pattern” of “sub-optimal care” which led to considerable harm, while also revealing how the concerns of families were ignored. It added that East Kent NHS Hospitals Trust had given the appearance of “covering up the scale and systematic nature” of its issues.

Furthermore, investigators found that the trust wrongly took comfort in that most births occurring at East Kent ended with no injury to mother or baby. However, the report laid bare the fact that harm was not just limited to physical injury, and that there were multiple instances were hospital staff showed a lack of compassion and kindness to patients - even in the aftermath of injury or death.

"Gross failures"

The review found “gross failures” of team-working across maternity services, stating: "The dysfunctional working we have found between and within professional groups has been fundamental to the sub-optimal care provided in both hospitals."

Dr Kirkup’s report comes after a series of failings were highlighted during the inquest of Harry Richford, who was just 7 days old when he died in 2017. Three years after his death, a hearing found that Harry’s death at The Queen Elizabeth the Queen Mother Hospital was “wholly unavoidable”.

After initially saying that Harry’s death was “expected” the trust later apologised to his family. However, this was not the first incident of its kind within East Kent NHS Trust. In 2012, Harry Halligan almost died following mistakes made by hospital staff during his delivery at William Harvey in Ashford. This sparked the Care Quality Commission – rating the trust’s maternity services as “inadequate” - to put the trust under special measures.

Despite various directives for improvement being made, almost no recommendations were implemented. The family of Harry Richford claim their son might not have died if the trust had learned from the mistakes made during the case of Harry Halligan. They have since spent years fighting for systematic changes at East Kent maternity units.

Following the release of the report last week, Dr Kirkup told reporters the most disturbing thing to come to light in the review were the behaviours and attitudes of trust staff towards families with genuine complaints.

"Deplorable and harrowing"

Dr Kirkup noted that a total of 45 of the 65 baby deaths that occurred during the review period could have had a different outcome, adding the scale of the failings at the trust was "deplorable and harrowing".

Dr Kirkup, who also chaired the investigation into Morcambe Bay services, said that on at least eight occasions over a ten-year period, board members at the trust were presented with "inescapable signals" there were serious issues.

A prominent theme which emerged during the East Kent review was the presence of "challenging personalities, big egos, huge egos", with one group dubbed "the A-team".

A lack of compassion was also highlighted, with one woman "dismissively" told during an antenatal check to look up extra information on Google.

Tracey Fletcher, East Kent NHS Hospitals Trust chief executive said she apologised unreservedly for the "harm and suffering" caused and said the trust would act on the report, on behalf of "those who we will care for in the future and for our local communities", adding: "I know that everyone at the trust is committed to doing that."

According to Ms Fletcher, the trust had increased numbers of midwives and doctors, and invested in staff training and in listening to and acting on feedback from the people who receive its care.

Helen Budge, a Senior Solicitor within our Clinical Negligence team, comments here:

My heart goes out to the families who have lost babies as a result of unsafe care at these two hospitals, as well as those children who have been left with life changing brain injuries.

I represented some of the parents affected by the Morecambe Bay scandal, which was the subject of the last Kirkup report. It is so disheartening to see the same themes being repeated in East Kent: poor teamwork among and between midwifery staff and doctors; a lack of care and compassion; a culture of defensiveness.

While most babies are safely delivered in NHS hospitals, it is becoming increasingly clear that there is a childbirth lottery. Some women who gave birth in East Kent or Morecambe Bay, or indeed in Shrewsbury or Nottingham, received care which fell far below that which they and their babies were entitled to expect. The NHS must improve how it identifies and manages failing maternity units, and it must do so urgently before more lives are lost.

Helen Budge is a Senior Solicitor within Potter Rees Dolan's Clinical Negligence department. If you have any questions relating to this story or clinical negligence generally and wish to speak with Helen, please call our free phone on 0800 027 2557. Alternatively, you can contact Helen directly through her profile page on our website.