Shocking New Report Finds Dozens of Maternity Deaths Due to Substandard Care

Sarah and Tom Richford, with their son Harry, said their concerns about their son’s death had been repeatedly brushed aside by managers .

Dozens of babies and mothers died or were injured during childbirth because of repeated failings in maternity care at a major NHS trust, a damning report has found.

Dr Bill Kirkup, who led the investigation, said his findings into substandard care at the East Kent trust between 2009 and 2020 were “shocking and uncomfortable” and had had a catastrophic impact on families.

Kirkup’s scathing report is the second this year, and the third since 2015, to expose what he called “embedded, deep-rooted problems” in the way the health service looks after pregnant women and their children.

His almost three-year-long inquiry identified an array of serious problems with maternity services at the trust’s William Harvey hospital in Ashford and Queen Elizabeth the Queen Mother hospital in Margate.

“What has happened in East Kent is deplorable,” he said at the report’s launch yesterday.

A report in March found similar problems at the Shrewsbury and Telford trust.

Babies and their mothers suffered “significant harm” at East Kent as a result of “suboptimal care”, which was the result of poor decision-making by staff and infighting among and between midwives and obstetricians, the report said.

The trust allowed huge tensions within its maternity workforce to continue, got rid of managers who tried to address problems – and in some cases even blamed mothers for the deaths of their children.

Kirkup castigated the trust and its leadership during the 11 years in question for covering up the extent .

‘I want to apologise unreservedly for the harm and suffering experienced’

Of the harm done to women and babies. That was part of a culture of “deflection and denial”, which was a “cruel practice” that exacerbated the trauma families were experiencing.

In almost half the 202 cases of death and harm Kirkup and his team looked into, the mother or baby would have had a different outcome if trust staff had followed nationally accepted standards of care.

For example, of the 65 baby deaths they probed, 45 of the newborns could or may have lived if they had had what medical bodies and regulators say are the standards of care all pregnant women and their sons and daughters should always receive.

Twelve of 17 newborns who suffered brain damage might not have done so if they had been looked after properly.

Similarly, 23 of 32 mothers would not have suffered injury or died while giving birth.

Kirkup’s 192-page report detailed some horrific practices and behaviour, and a dangerous culture, at the two hospitals’ maternity units, including:

• Squabbling between midwives, obstetricians, paediatricians and other groups of staff which involved “factionalism and … bullying”.

• Junior obstetricians and midwives getting the blame for errors committed by more senior colleagues.

• Midwives not part of the midwifery team’s “A-team” being given the highest-risk mothers to care for – “a downright dangerous practice”.

• Mothers being given too little pain relief, ignored when they sought to raise concerns and spoken to with a lack of compassion, with one who had lost her baby told: “It’s God’s will; God only takes the babies that he wants to take.”

He also found a series of failings by the trust’s chiefs, including missing eight opportunities during 2009-20 to acknowledge the extent of problems and solve them and regarding the trust as a “victim” of external factors causing its poor maternity care.

The report warns maternity services across the NHS need to take urgent action to tackle “longstanding issues [that have] become deeply embedded and difficult to change”.

Birte Harlev-Lam, the executive director for professional leadership at the Royal College of Midwives, said too many maternity units displayed “toxic cultures that put women and babies at risk”.

Kirkup, an obstetrician and expert in patient safety, vindicated claims by some bereaved parents that the trust had been guilty of “victim blaming” mothers for their children’s deaths.

Tracey Fletcher East Kent trust chief executive

Kelli Rudolph and Dunstan Lowe, whose daughter Celandine died at five days old, said: “Doctors sought to blame Kelli for Celandine’s death.

This victim-blaming was the first in a long line of interactions with those in the trust who sought to delay, deflect and deny our search for the truth about what happened to our baby.

“In isolation, these tactics traumatised us after the tragedy of our daughter’s death.

But when seen in the light of 10 years of failures, they signal a concerted effort to cover up the trust’s responsibility for failures in clinical judgement.”

Helen Gittos and Andy Hudson, whose full-term, healthy daughter Harriet died in 2014, said: “Rather than being listened to, we were treated dismissively, contemptuously and without a desire for understanding.”

The family of Harry Richford, who died a week after being born at the Queen Elizabeth The Queen Mother Hospital in 2017, have long campaigned for answers after saying their concerns were repeatedly brushed aside by hospital managers.

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 the baby boy.

Harry’s grandfather Derek, who painstakingly gathered evidence about East Kent, said on Twitter his family was taking time to heal following the report’s publication.

He tweeted: “It is time for me to hand over the baton of maternity safety to others.”

Responding to the new report, Danielle Clark, mother to Noah, whose case was also investigated, said: “People need to be held accountable.

Things have got to change.

Babies are dying just through bad care.”

Jacqueline Dunkley-Bent and Matthew Jolly, NHS England’s chief midwifery officer and national clinical director for maternity care, said that as a result of Kirkup’s findings .

“we will work closely with trusts in England to make every necessary improvement and ensure that all our services are as safe as possible for mothers, babies and their families”.

Tracey Fletcher, the trust’s chief executive, 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.”

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