East Kent NHS trust baby deaths: "It is too late to pretend that this is just another one-off, isolated failure", says author of report

Posted: 25/10/2022

Maternity care has tragically been found wanting at yet another NHS trust, with catastrophic failings already having been identified at Shrewsbury and Telford Hospital NHS Trust earlier this year, as addressed in Donna Ockenden’s report.

Dr Bill Kirkup was engaged by NHS England and NHS Improvement to undertake an independent review into maternity deaths at East Kent Hospitals University NHS Foundation Trust. In particular, he was focused on care at the Queen Elizabeth the Queen Mother Hospital and the William Harvey Hospital between 2009 and 2020.

His report concluded that ‘suboptimal care’ had led to ’significant harm’ to patients over this period and identified that out of the 65 baby deaths considered, 45 babies could or may have lived if nationally recognised standards of care had been provided. Additionally, in 17 cases of brain damage sustained perinatally by babies, there could have been a different outcome if good care had been provided. Several avoidable maternal injuries and deaths were also identified.

The report sought to identify what was behind these distressing statistics and noted that:

• there were ‘gross failures of teamworking’ with dysfunctional working between and within professional groups (that is, midwives, obstetricians and paediatricians);
• there were ‘clear and repeated failures in professionalism’ with staff being disrespectful to those in their care and ‘disparaging about the capabilities of colleagues’ in front of patients and their families;
• there was a lack of compassion on the part of staff;
• there was a failure to listen to patients or other staff and a ‘pattern’ of ‘dismissing what was said’;
• safety incidents were not addressed properly with denials of responsibility and blame even being placed on patients when things went wrong; and
• the blame culture was also evident at trust board level, with junior staff and locums being blamed for failings.

Dr Kirkup noted that the report was to ‘set out the truth of what happened … so that maternity services in East Kent can begin to meet the standards expected nationally’. But he noted that this was ’not enough’ and that it was ‘too late to pretend that this is just another one-off isolated failure’ that ‘will never happen again’, given the major failings at Morecambe Bay, Shrewsbury and Telford and, it seems, Nottingham.

A series of recommendations has been made, including:

• the establishment of a task force to introduce valid maternity and neonatal outcome measures;
• that those responsible for training staff report on how best to embed compassionate care into practice;
• a focus on improved teamworking;
• asking the Government to reconsider bringing forward a bill placing a duty on public bodies not to ‘deny, deflect and conceal information from families and other bodies’; and
• that East Kent Hospitals University NHS Foundation Trust accepts the findings, acknowledges the harm caused and embarks on a ‘restorative process addressing the problems identified’.

If you have concerns about the standard of maternity care you or a loved one has received, our specialist solicitors may be able to help. Please call us on 0800 328 9545, email clinnegspecialist@penningtonslaw.com or complete our online assessment form.

Related articles

The Shrewsbury and Telford Hospital Trust maternity review: a timeline of events leading to a police investigation into maternity care

Interim report on maternity care at Shrewsbury and Telford NHS Trust: a summary of findings

FAQs on maternity care at the Shrewsbury and Telford hospital NHS Trust

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