East Kent - a devastating report.

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

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

His damming report is the second in 2022, and the third since 2015, to expose what he called “embedded, deep-rooted problems” in how the NHS cares for pregnant women and their babies.

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

Revealing the findings of the investigation report, Dr Kirkup said:  “What has happened in East Kent is deplorable and harrowing.” 

He said that babies and their mothers visiting East Kent Hospital Trust suffered “significant harm” due to “suboptimal care”, caused by poor decision-making by key staff and infighting within and between midwives and obstetricians.

According to the investigation report, the trust tolerated huge tensions within its maternity workforce, got rid of managers who tried to address the problems and, in some shocking cases, even blamed mothers for their child’s death.

Dr Kirkup, an associate chief medical officer for England, castigated the trust and its leadership for covering up the extent of the harm done to women and babies during the 11 years examined by the investigation.

He said that it 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, Dr Kirkup and his team investigated, the mother or baby would have had a different outcome if trust staff had followed nationally accepted care standards.

For example, of the 65 baby deaths they investigated, 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 babies should always receive.

Twelve of 17 newborns who suffered brain damage may 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 if they had received good care.

Dr 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, lack of mutual trust and bullying.”

The report said that junior obstetricians and midwives often got the blame for errors committed by more senior colleagues. Midwives, who were not part of the midwifery “A-team”, were given the highest-risk mothers to care for -  “a downright dangerous practice.”

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

Another, named only as C, was left bleeding after a traumatic delivery with her family told that staff: “are all in the staffroom having a cup of tea to recover.” The woman’s baby died the following day.

Dr Kirkup, who also carried out investigations into Morecambe Bay maternity services and children’s heart surgery in Oxford, also found that East Kent trust managers missed eight opportunities during 2009-20 to acknowledge the extent of problems and solve them.

The report said that managers compounded families’ suffering by not being open and honest. They viewed the trust as a “victim” of external factors that were causing its poor maternity care, such as lack of staff and its coastal location, and did not understand that the real causes were internal and involved “failures in team-working, professionalism, compassion and listening.”  

The report tells NHS managers, ministers and heath professionals that the dangerous dysfunction at East Kent, allied to other maternity care scandals, means “it is too late to pretend that this is just another one-off, isolated failure, a freak event that ‘will never happen again’.”

It said that maternity services across the NHS need to take urgent action to tackle “longstanding issues that have become deeply embedded and difficult to change.”

To improve patient safety, hospitals must do much more to identify problems that arise in maternity units much faster, ensure better team-working between midwives and obstetricians, make care kinder and more compassionate and be honest when mistakes are made.

The report says that, if they do not do so, other scandals like East Kent are inevitable.

Reacting to the report’s findings, one former patient, Bex Walton, whose son Tommy died in 2020, two days after being born at the William Harvey Hospital in Ashford, said: "I will never be able to forgive. Nothing they do now will be good enough because my boy will never be with me ever again."

In another case, a series of failings emerged during the inquest of Harry Richford, who died seven days after being born in 2017. The hearing in January 2020 found Harry's death at The Queen Elizabeth the Queen Mother Hospital (QEQM) in Margate was "wholly avoidable.”

Another baby, Harry Halligan nearly died in 2012 following mistakes during his delivery at the William Harvey.

Afterwards, the trust was put into special measures by the health and care regulator, Care Quality Commission, which rated its maternity services as "inadequate.”

After the report’s publication, grieving parents said this had to be the last NHS maternity scandal, while asking why there had not been more of an outcry about “two full classrooms of children who never came home.”

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 what happened to Celandine and the many others who lost their lives due to failures in clinical judgment.”

Danielle Clark suffered a traumatic birth with her son Noah, now nine, and felt her concerns were dismissed because she was a first-time mother.

She said: “People need to be held accountable. Things have got to change. Babies are dying just through bad care and pure neglect.”

Helen Gittos and Andy Hudson, whose full-term, healthy daughter, Harriet, died in 2014, said: “Too often during pregnancy, in labour and afterwards rather than being listened to, we were treated dismissively, contemptuously and without a desire for understanding. It is hard enough to come to terms with the death of a child; it is even harder when you are implicitly blamed for what happened.”

Meanwhile grandmother, Lyn Richardson, criticised the Trust for a 'catalogue of failings' around the birth of her grandson that she claims contributed to her daughter taking her own life.

She said her daughter, Rebecca Kruza, 39, killed herself in 2017 months after the “traumatic” birth in October 2016 at the William Harvey Hospital in Ashford, Kent.

Ms Richardson said her daughter had post-natal issues while her grandson suffered from health problems early on. She claimed doctors did not take her daughter's concerns seriously and that this was one of the reasons she took her own life.

Ms Richardson said: “From the day of the birth, right up until we lost Rebecca eight months later, there was a catalogue of failings. There's just a complete lack of understanding of what mothers need and what their babies need. She was failed by nearly every professional involved in her care.

“She had a traumatic birth which was very badly managed, the immediate post-natal care was very badly managed when she developed problems.”

Ms Richardson added that her daughter had been on mental health medication and seeing a counsellor before her death.

She has since set up a foundation in her daughter's memory to campaign for improvements to maternal care.

The foundation, Everglow: The Rebecca Kruza Campaign, submitted evidence to the Kirkup inquiry providing details of Rebecca's case and the experiences of a number of other parents and is calling for a number of measures to be implemented.

Trust chief executive, Tracey Fletcher, 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. These families came to us expecting that we would care for them safely, and we failed them.”

Ms Fletcher 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. I know that everyone at the Trust is committed to doing that."

Ms Fletcher added that 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.

NHS England’s chief midwifery officer and national clinical director for maternity care, Jacqueline Dunkley-Bent and Matthew Jolly, said that as a result of Kirkup’s findings “We will work closely with Trusts in England and our partners to make every necessary improvement and ensure that all or services are as safe as possible for mothers, babies and their families.

Commenting on the report, Kim Daniells of the CNCI team said, "This is the second significant, and shocking, report about maternity failings that we have covered this year. Even for those of us who hear regularly from women who have encountered serious problems in maternity care, Bill Kirkup's findings are absolutely devastating. Women, their babies and their families were abjectly failed at every step by the professionals whose job it was to care for them. We hope that the report's findings are addressed urgently, and that lessons are learnt immediately, so that these failings are never repeated elsewhere."