Dozens of babies died or were left brain damaged by poor care at East Kent Hospitals University NHS Foundation Trust, a damning independent inquiry has found, with the treatment of many women and babies at hospitals run by the trust described as “deplorable and harrowing”.
Revealing the findings of the report last week, chairman of the panel Dr Bill Kirkup said he had held meetings last week with some of affected families who displayed “a great deal of emotion and substantial amount of anger”.
In total, more than 200 cases dating back to 2009 have been looked at by the expert panel chaired by Kirkup, who also led the investigation into mother and baby deaths in Morecambe Bay in 2015.
The 182-page study marks the culmination of an independent inquiry into maternity and neonatal services and newborn babies at East Kent Hospitals University NHS Foundation Trust from 2009.
Kirkup said families received “suboptimal” care, with mothers ignored by staff and shut out from their own care, reports ITV.
“An overriding theme, raised with us time and time again, is the failure of the trust’s staff to take notice of women when they raised concerns, when they questioned their care, and when they challenged the decisions that were made about their care,” the report said.
Of 202 cases reviewed by the experts, the outcome could have been different in 97 cases, the inquiry found.
In 69 of these 97 cases, it is predicted the outcome should reasonably have been different and could have been different in a further 28 cases. Of the 65 baby deaths examined, 45 could have had a different outcome if nationally recognised standards of care had been provided.
When looking at 33 of these 45 cases, the outcome would reasonably expected to have been different, while in a further 12 cases it might have been different.
Meanwhile, in 17 cases of brain damage, 12 (72% of cases) could have had a different outcome if good care had been given, of which nine should reasonably have been expected to have had a different outcome.
In nearly half of all cases examined by the panel, good care could have led to a different outcome for the families.
In his report, Kirkup said he had “no doubt” there are more cases of failings that the panel hadn’t even investigated, reports KentOnline. The report also highlighted “clear and repeated” failures of professionalism from staff at the hospitals – that staff were disrespectful to women and disparaging to colleagues in front of them.
Others sought to deflect responsibility, some even blaming the mothers themselves for their own misfortune.
A mother whose daughter killed herself after a traumatic birth at The William Harvey Hospital (Kent) blasted the “catalogue of failings” she says contributed to her suicide
Lyn Richardson said her daughter Rebecca Kruza killed herself in 2017 months after the “traumatic” birth in October 2016.
She said her daughter had post-natal issues while her grandson suffered from health problems from the start; she also claimed doctors did not take her daughter’s concerns seriously, which she claimed was one of the reasons she took her own life.
“From the day of the birth right up until we lost Rebecca, eight months later, there was a series of failings,” reports the Daily Mail. “She was failed by nearly every professional involved in her care.”
She has since set up a foundation in her daughter's memory to campaign for improvements to maternal care. Called Everglow: The Rebecca Kruza Campaign, it 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 urgent measures to be implemented.
They include a mandatory duty of care for health visitors and GPs to support mothers and babies where symptoms of mental health emerge and introducing more frequent health checks from midwives in the post-natal period.
Responding to the Kirkup report, Richardson said: “I wasn’t surprised…What is available needs to be rebuilt from the bottom up and the government needs to provide the funding to implement those very simple measures and save the heartache.”
Mothers blamed for babies’ deaths
In the damning report, mothers give harrowing accounts of being blamed for what happened to their babies, being told their deaths were “God’s will”, and being left in soiled bedding.
The report found 45 babies who died at Queen Elizabeth The Queen Mother Hospital (QEQM) at Margate and the William Harvey Hospital in Ashford could have survived if they had received better care.
Families were “disregarded, belittled and blamed”, while there were instances where doctors and midwives tried to abdicate responsibility or shift blame on to others when things went wrong, the report found.
One mother described being taken into a “tiny little box room” and being told by medical staff: “As long as you know, it is not our fault. It is no one’s fault. It is just one of those things.”
Families also spoke of their pain for not being given answers or reasons for why things went wrong. One bereaved mother told the panel: “My opinion will always be that (my baby) died because somebody didn’t do their job properly.
“It has affected me, my husband, our son. It’s devastating and it can’t be undone, it’s what we just have to live with.”
During one heart-breaking testimony, adds the Daily Mail, another bereaved mother told the panel: “Although it was seven years ago for us, it is still burning in our hearts because we haven’t had answers.”
In one particularly cruel instance, a woman was denied access to a bereavement counsellor because she was not having a funeral for her baby.
“We asked to see the bereavement counsellor, and she refused to see us because we weren’t having a funeral, she was like, well, there’s nothing I can do for you,” the bereaved mother said.
One husband recalled a midwife saying of his wife: “She’s making the wrong call here, and it’s going to be your wife’s fault when it all goes wrong.”
Another mother whose baby died was told by a midwife that it was “God’s will; God only takes the babies that he wants to take”.
Kirkup added that the panel had “not been able to detect any discernible improvement in outcomes or suboptimal care, as evidenced by the cases assessed over the period from 2009 to 2020.”
“We have no doubt that these numbers are minimum estimates of the frequency of harm over the period,” he said.
In response to the findings, Chief Executive of East Kent Hospitals University NHS Foundation Trust Tracey Fletcher said: “I want to say sorry and apologise unreservedly for the harm and suffering experienced by the women and babies who were within our care, and with their families,” reports ITV.
“They came to us expecting that we would care for them safely, and we failed them.
“We must now learn from and act on this report; for those who have taken part in the investigation, for 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.
“In the past few years we have worked hard to improve our services and have invested in increasing the numbers of midwives and doctors, in staff training, and in listening to and acting on feedback from the people who receive our care.
“While we have made progress, we know there is more for us to do and we absolutely accept that. Now that we have received the report, we will read it in full and the Board will use its recommendations to continue to make improvements so that we are providing the safe, high-quality care our patients expect and deserve.”
Meanwhile, reports The Independent, Britain's care watchdog has raised “deep concerns” as two in five maternity services are now deemed not good enough, with the Care Quality Commission (CQC) saying maternity services are getting worse, and inspectors “time and again” finding issues with the leadership and culture within units.
The regulator’s annual State of Care report also said that historic underinvestment in health and social care has led to a “gridlocked” system.
CQC chief executive Ian Trenholm said the recruitment challenge trusts face “is going to translate into real difficulty” this winter and in the years ahead.
The CQC boss said one-quarter of inspections resulted in enforcement action against a provider, adding this was a signal that services are struggling to cope.
The report warns staff shortages across NHS and social care services are driving the current problems and in some examples having a “severe impact” on people’s human rights.
Responding to the report, NHS Providers’ interim chief executive Saffron Cordery said: “The regulator’s hard-hitting report makes clear that people’s care is affected by chronic staff shortages across the health and care system and must be a wake-up call for the government.
“Inadequate funding for and lack of capacity in social care have serious knock-on effects on an overloaded NHS. People need support to stay well and live independently in the community which would in many cases prevent, or delay, the need for hospital care.”
Worsening maternity services
Data shared by the CQC showed that as of July 2022, 6% of maternity services were rated “inadequate” and 32% rated “requires improvement”, the the worst since a maternity category was first introduced in 2018.
The regulator said its data showed the “quality of maternity services is getting worse”.
Pointing to reports which show black women are four times more likely than white women to die in pregnancy or childbirth, Trenholm said: “[It is] simply unacceptable in this day and age for black women to have a such a bad experience of care in comparison to white women.”
The report added: “During our inspections, we have seen the effect of staff shortages, such as a lack of midwife leaders, causing inconsistent practice and difficulty in embedding a good culture. In some cases, staff shortages can have a severe impact on people’s human rights.”
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Daily Mail article – Mother whose daughter, 39, killed herself after ‘traumatic’ birth at maternity-scandal hit hospital blasts 'catalogue of failings' she says contributed to her suicide (Open access)
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