East Kent baby deaths: Independent review into NHS trust

Image source, Family handout
Image caption,
Harry Richford would have survived but for failings by the hospital

An independent review will be held into maternity services at the East Kent NHS Trust after up to 15 babies died there in recent years.

Nadine Dorries, minister for patient safety, pledged immediate action and said NHS England would investigate the two hospitals in Margate and Ashford.

On Wednesday the trust's chief executive said there had been "six or seven" avoidable deaths since 2011.

However, on Thursday a board meeting heard there were 15 possible deaths.

Speaking in the House of Commons earlier Ms Dorries said: "NHS England and NHS improvements are commissioning themselves an independent review into East Kent maternity services."

She said the trust was having issues with "ensuring the right staff with the right skills in the right place".

She added that midwives and doctors working clearly together was a problem, along with communication and leadership support.

Image source, Family handout
Image caption,
Harry Richford suffered irreversible brain damage during resuscitation delays

NHS England and NHS Improvement has revealed Dr Bill Kirkup CBE will carry out a review into the circumstances of maternity deaths at the trust.

Dr Kirkup, who will meet the families affected, has led several public investigations including chairing the investigation of Morecambe Bay maternity services.

An independent support team has already been sent into the trust to ensure improvements are carried out.

'Very much needed'

A series of failings came to light during the inquest of Harry Richford, who died seven days after being born at the Queen Elizabeth the Queen Mother Hospital in Margate in November 2017.

Harry's grandfather Derek Richford, who the trust previously accused of "undermining" its reputation, told the BBC he was "delighted" about the review.

He added: "This is very much needed for the other families.

"We do need to know the extent of the problems before the appropriate actions can be put in place."

On Wednesday Susan Acott, chief executive of the trust, said there had been "six or seven" avoidable deaths at the trust, including the William Harvey Hospital in Ashford, since 2011.

However, during a board meeting on Thursday Ms Acott said there were actually 15 possibly preventable baby deaths.

Ms Acott was asked by a public governor if she would resign from her role.

She declined, saying "continuity" was "particularly important".

She added: "We need to use the memory of Harry Richford to just really maintain our energy and focus."

'Most harrowing call'

The Department of Health and Social Care is examining 25 individual maternity cases, and the Healthcare Safety Investigation Branch (HSIB) and Care Quality Commission (CQC) are also investigating the trust.

Image caption,
Sir Roger Gale, MP for North Thanet, addressed the Commons earlier

North Thanet MP Sir Roger Gale earlier asked an urgent question and told the Commons: "This morning at an early hour I spoke with, for half an hour, a husband and wife living now in Australia who two months after the death of Harry Richford lost their own child under similarly tragic circumstances - and it was the most harrowing phone call I've ever taken in 36 years in this House of Commons.

"They deserve and need the opportunity to achieve closure and move forward.

"These parents need to know that the failures in protocol, that the failures in clinical judgement and that the failings in management have been addressed."

Sir Roger said an independent inquiry would ensure the parents of Harry and others "will know that their children have not died in vain and that this will never, ever happen again".

Image caption,
Susan Acott earlier told a meeting she would not resign as chief executive of the hospital trust

Canterbury MP Rosie Duffield said women in her constituency were "terrified" about using maternity services.

She added: "There are so many questions from my constituents.

"Dozens of whom are now really terrified about their future pregnancies and having babies in the area."

Tom Richford, baby Harry's father, said he was looking forward to meeting Dr Kirkup and said he wanted to highlight all the information they had gathered as a family.

"We've got a number of areas which we think are quite focal to look at going forward," he said.

"If those individuals who are leading the inquiry could look into all of those areas I believe they would find a number of significant failings."

The independent clinical support team sent into the trust includes a director of midwifery services from a CQC-rated outstanding trust, two consultant obstetricians and a consultant paediatrician and neonatologist.

'Wholeheartedly apologise'

Ms Dorries said the very best had been placed "at the heart of the trust - on the wards, at the bedside of patients".

A spokesman for East Kent Hospitals said: "To date the medical director has reviewed perinatal deaths on our incident reporting system between 2012-19 and has identified 15 wholly or potentially preventable perinatal deaths, all of which have been investigated.

"As a result the chief executive has asked the medical director to do a detailed review supported by the independent medical consultants who are now working with the trust."

The spokesman added: "We know that we have not always provided the standard of care for every woman and baby that they expected and deserved, and wholeheartedly apologise to every one of those families we have let down.

"Around 7,000 women give birth under our care each year, and one death that could be prevented is one too many. We will not rest until we are delivering an outstanding maternity service that has the full confidence of all families in east Kent."

A meeting with the trust, CQC and "key health system partners" is scheduled for 21 February to check the action so far and made any further necessary interventions.

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