East Kent maternity failings led to 45 baby deaths, damning report reveals

Poor care may have led to the deaths of 45 babies, with 97 cases of harm, injury or death to mothers overall which may have been avoided in east Kent, a major maternity inquiry has found.

The review looked at more than 200 cases spanning more than a decade of maternity failings by East Kent Hospitals University Trust and found a “pattern of recurring harm” at the trust.

It was found that in 97 out of the 202 cases, the outcome for the mothers or babies could have been different. Of those 45 babies deaths may have been avoided, 12 babies may not have suffered brain damage and in 23 mothers may not have died or been injured.

In 54 patients care they found failings but determined this would not have changed the outcome.

The review was led by Dr Bill Kirkup, who also led the 2015 review into the failings at Morcambe Bay hospital that led to the deaths of 16 babies and three mothers.

Speaking at a press conference Dr Kirkup said what had happened in east Kent was “deplorable” and “harrowing.”

“When I reported on Morecambe maternity services in 2015. I did not imagine the courtroom or similar set of circumstances seven years later,” he said.

If you have been impacted by poor maternity care or failings email rebecca.thomas@independent.co.uk

Dr Kirkup has said in a letter to the health secretary Therese Coffey that the failings in Kent are not a “one-off”, warning if the NHS does not begin to tackle poor maternity care more inquiries will follow.

Reviewers said from a series of reports from 2009 to 2020 meant failings were visible to senior managers and the trust board, and that problems could have been acknowledge and tackled.

The report, published Wednesday, has found:

The probe, led by Dr Bill Kirkup, was commissioned by the government after The Independent revealed more than 130 infants suffered brain injuries during birth at the trust over several years.

Dr Kirkup and the review team has called for national action and warned “this must be the last such moment of failure, with the lessons leading to improvement not just locally but nationally.”

The scandal was exposed by the family of baby Harry Richford who died after a catalogue of errors by maternity staff in November 2017. A coroner ruled his death was the result of neglect and “wholly avoidable”.

In a landmark case, the trust was fined £761,000 following prosecution by the Care Quality Commission for the trust’s failure to protect baby Harry Richford and his mum Sarah Richford from avoidable mistakes that led to Harry’s death.

In October last year the CQC found staff shortages at the hospital had left midwives working 20-hour days with little time for a break.

The report follows the Shrewsbury Maternity scandal review published earlier this year which found failings at Shrewsbury and Telford Hospital Trust led to the deaths and brain injury of more than 250 babies.

More to follow…

‘I wasn’t listened to’

Emma Robinson’s, daughter Daisy died in 2014, just hours after her birth.

Speaking with The Independent she described how a week before her induction date she had to go to hospital due to migraines, high blood pressure, swelling and had protein in her urine.

However, she was told to keep her original induction date, 48 hours before this date she began getting labour pains. When she got to hospital for her inducement date her blood pressure was so high she had to have an epidural.

During her labour she said: “At some point they decided they came and spoke to me and they basically said you’re not progressing, we’re going to take the hormone drip away so you can sleep. You need a C-section, but your baby is not priority. There are two other moms in front of you and they need the C-section. They need their C-section because their babies are poorly and your baby is fine.”

She said: “I was just 19. I felt like they only listened to me when my mum was in the room because my mum was a nurse. I didn’t feel listened to. I feel I was stereotyped. I feel like no matter what I went there with, they knew better. They knew better. I think that is another thing that needs to change is the voice of parent.”

Shortly after Daisy was born staff had to rush her for resuscitation and tragically more than an hour later Emma was told she was not responding.

After Daisy’s death, Ms Robinson was placed on a ward with other women who had given birth and had their babies.

She said: “I just felt so numb to the world like the whole time and everything that went on was so fuzzy, I cried so much. I just I think it’s disgusting now when I look back on it and but it’s I suffer with really bad anxiety since it’s losing Daisy. It was really emotional and really hard to have to listen to other people knowing that I’m not going to have my baby.”

A coroner later determined Daisy had died from sudden infant death syndrome. However, Emma said her placenta was not kept for testing and so pre-eclampsia could not be determined.

A trust investigation into Daisy’s death, Ms Robinson claims incorrectly recorded she had refused a c-section.

She said: “We were constantly told they were short staffed on the night, we were constantly told that Daisy had to wait because her you know, when they watched the heartbeat, we were constantly told Daisy was fine, she was she was less of a priority. These other two moms were a priority, their babies are still here but mine isn’t.”

“I feel they failed both of us and I feel that Daisy paid the price. I feel like it’s as raw as it was in 201 because haven’t got the answers…I don’t want other mums to go through this. Hopefully this report will change the care in maternity.”