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Up to 45 babies might not have died if they had received better care at East Kent Hospitals University NHS Foundation Trust, a damning independent report by Dr Bill Kirkup published this week (19 October 2022) has found.
Sadly, Dr Kirkup’s report into East Kent maternity services has revealed how – over 11 years – substandard care, a dangerous culture and a failure by the Trust’s management to act on warnings caused or contributed to:
Figures show that had better care been given to nationally recognised standards, the outcome could have been different in 97 of the total 202 cases reviewed – a staggering 48%. What’s more, there is no doubt there are more cases of maternity care failings that the panel have not even investigated.
The devastating findings underscore that necessary changes in NHS practice and culture have not been fully incorporated and are a sad reflection of unlearned lessons.
Dr Kirkup has said he “did not imagine” he would be talking about similar circumstances again following his investigation into Morecambe Bay in 2015.
Speaking on BBC Radio 4’s Today programme he said: “When I reported on Morecambe Bay maternity services in 2015, I did not imagine for one moment that I would be back in 7 years time talking about a rather similar set of circumstances and that there would have been another two large, high-profile maternity failures as well on top of that. This cannot go on. We have to address this in a different way. We can’t simply respond to each one as if it’s a one-off as if this is the last time this will happen. We have to do things differently.”
The report on East Kent is the second devastating analysis of NHS maternity services to be published in a matter of months. In July 2022 the Ockenden Report into Shrewsbury and Telford NHS Trust found that poor care led to the avoidable deaths of 201 babies.
A further inquiry has since begun into maternity services at Nottingham University Hospitals NHS Trust, again headed by Donna Ockenden.
This week’s publication of this report into East Kent Maternity Services follows a 5-year fight for justice by Derek Richford. He was desperately seeking answers after his grandson, Harry’s death at the Queen Elizabeth The Queen Mother Hospital in Margate, Kent, in 2017.
Harry’s family, including parents Sarah and Tom Richford, have consistently said their concerns were repeatedly brushed aside by hospital managers.
“An overriding theme, raised us with 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.
“What troubles me the most are the attitude and behaviour which dismissed women who had legitimate concerns and questions,” Dr Kirkup said.
A husband was asked as his wife cried out in pain: “Is she normally this dramatic with pain?”
Another was told: “It’s going to be your wife’s fault when it all goes wrong.”
One family, whose baby had suffered brain damage, asked staff how extensive the damage was, and were told: “Work it out yourself.”
One woman was left alone for two hours after childbirth, only for her family to realise that she was bleeding very heavily. After she was taken to intensive care, requiring a blood transfusion, a Consultant made an insensitive joke about “phoning a friend” for advice on treatment – in an apparent reference to the quiz show Who Wants to Be A Millionaire?
What is also clear is that there continues an overriding theme of a culture of deflection and denial, which only serves to deny families of the truth and cause even greater harm.
Unfortunately, the themes in the report – poor teamwork, a lack of kindness and compassion, a lack of honesty when things go wrong, and an institutionalised culture of denial – have all been identified many times before.
The Report calls for 4 key changes:
“I am extremely saddened that women and their birthing partners are still not being listened to, with their concerns often dangerously disregarded. A lack of compassion and kindness is something that sticks in a person’s mind for a long time. Our medical negligence team often have people approaching us with their deep concerns about the complete lack of empathy they have experienced in hospital during what is often the worst and most traumatic times of their lives.
“It is clear that those who approach us for advice and legal support is that they want to be listened to and heard. They want to be involved and informed; to understand what went wrong; to have answers with compassion, understanding and support; and to prevent something similar from happening again.
“It is vital for those involved in delivering maternity care services to work together with a shared goal and vision for the future. There is no space for defensive and divisive attitudes. Compassion is the way forward.”
If you have any concerns about the treatment you and your baby have received in a hospital or any other healthcare setting, Novum Law’s team of specialist medical negligence solicitors can help on a no-win, no-fee basis.
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