Up to 45 of 65 baby deaths at East Kent NHS Trust could have had a different outcome, a report says.
Image source, Family handoutUp to 45 babies might have survived if they had received better care at East Kent NHS Hospitals Trust, a damning independent review has found.
It found a “clear pattern” of “sub-optimal” care that led to significant harm and families were not listened to.
The medical experts reviewed an 11-year period from 2009 at two hospitals in Margate and Ashford.
The trust, which previously said it was “determined to learn any lessons”, has been heavily criticised by parents.
The independent review, which was chaired by Dr Bill Kirkup CBE, added the trust had given the appearance of “covering up the scale and systemic nature” of its problems.
Families called for people at the trust to be held accountable.
One mother, Danielle Clark, whose case formed part of the review, said: “Things have got to change. Babies are dying just through bad care and pure neglect.”
Chancellor Jeremy Hunt said the scandal was “simply unthinkable”. Health minister Dr Caroline Johnson apologised to the families and said the government was committed to preventing future tragedies.
Investigators said the trust wrongly took comfort from the fact most births at East Kent ended with no damage to mother or baby.
They found harm was not just restricted to physical damage, and there was repeated lack of kindness and compassion even in the aftermath of injuries and deaths.
Dr Kirkup’s team also found “gross failures” of team-working across the trust’s maternity services, with some staff acting as if they were responsible for “separate fiefdoms, cultivating a culture of tribalism”.
“The dysfunctional working we have found between and within professional groups has been fundamental to the suboptimal care provided in both hospitals,” the report said.
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”.
The trust has apologised for Harry’s death, which it initially said was “expected”. However it was not the first incident of its kind.
Harry Halligan nearly died in 2012 following mistakes during his delivery at the William Harvey Hospital in Ashford.
Afterwards, the trust was put into special measures by the Care Quality Commission, which rated its maternity services as “inadequate”.
Analysis
By Mark Norman, BBC South East health correspondent
Many families believed they were treated with contempt by the hospital trust and its staff.
Treated with contempt when they asked why their baby had died.
Treated with contempt when they asked for an investigation or a coroner’s inquest.
Treated with contempt when they questioned the trust about its responses and treated with contempt when they asked why investigations were taking so long.
But looking beyond the treatment they received, every family I have spoken to wants change.
Systemic, transparent change in the way the hospital trust runs its maternity departments, in the way it handles mistakes and errors on the part of its staff. And change in the way it treats families.
Directives for improvement were made, but the trust failed to implement almost all the recommendations.
Harry Richford’s family claim their baby might not have died if the trust had learned from the case of Harry Halligan, and have spent years demanding systemic change at East Kent’s maternity units.
Speaking to reporters following the release of the report, Dr Kirkup said the most troubling aspects of his review were the attitude and behaviours of some trust staff towards families with legitimate complaints.
He called for change to be implemented at the trust as soon as possible but added it will take time.
This video can not be played
To play this video you need to enable JavaScript in your browser.
Dr Kirkup said 45 of the 65 baby deaths that occurred during the review period could have had a different outcome.
He said the scale of the failings at the trust was “deplorable and harrowing” and that there was anger among families he had met.
On at least eight occasions over a 10-year period, the trust board was presented with “inescapable signals” there were serious problems, Dr Kirkup said.
A prominent theme which emerged during the review was the presence of “challenging personalities, big egos, huge egos”, with one group dubbed “the A-team”.
An external assessor with wide NHS experience said the trust had the worst culture they had seen, while another said they had not encountered such behaviour anywhere else.
Dr Kirkup has previously led several reviews, including chairing the investigation of Morecambe Bay maternity services.
Nadine Dorries, the former minister for patient safety, announced in February 2020 that the review at East Kent would be held.
The report was originally intended to be published last month, but was delayed following the death of Queen Elizabeth II.
If you have been affected by any issues in this story you can contact the BBC Action Line for advice.