Forty-five babies have died needlessly at the East Kent Hospitals Trust, a scathing review revealed today as investigators uncovered a string of ‘deplorable’ failures by NHS staff.
Affected families described being “neglected, belittled and blamed,” with mothers feeling responsible for tragic incidents.
But it’s not the only pregnancy scandal rocking the NHS. And it’s not even the first this year.
dr. Bill Kirkup, chair of the study, led an eerily similar study into preventable infant deaths in Morecambe Bay, which concluded in 2015.
Tellingly, at today’s press conference, where “shattering details of the East Kent scandal emerged,” he told “I didn’t think I’d be reporting back on similar circumstances seven years later.”
Queen Elizabeth the Queen Mother Hospital in Margate is one of the hospitals criticized in East Kent Hospitals University NHS Foundation Trust’s new maternity care assessment. The review found that 45 dead babies could have lived with better care
‘Deplorable and harrowing’: key findings of Dr. Kirkup
The panel examined an 11-year period from 2009 in two maternity wards in Margate and Ashford, Kent, and found:
- Up to 45 babies might have survived if they had received better care
- Babies died while others were left badly injured due to failings at East Kent NHS Trust
- Report found ‘clear pattern’ of ‘sub-optimal care’ leading to significant damage
- Not listening to families, as well as ‘culture of distraction and denial’
- Staff acted in a way that made families’ experience ‘unacceptable and harrowingly bad’
- Panel heard examples of uncompassionate concern ‘that shocked us’, a culture of blaming women, poor teamwork, a lack of professionalism and a tendency to shirk responsibility when things went wrong
- Trust prioritized reputation management at the expense of being open and clear to families
Just seven months ago, the biggest maternity scandal in NHS history was revealed after an investigation into Shrewsbury and Telford Hospital NHS Trust revealed that 201 babies and nine mothers died during two decades of appalling care.
It found that substandard care and defensive practices led to babies dying unnecessarily.
A separate investigation into a catalog of failures at Nottingham University Hospitals is also underway. Dozens of families have complained about the death or injury of babies and mothers.
The Morecambe Bay report was led by Dr Bill Kirkup, the man behind the new East Kent research.
His team found that 11 babies and one mother died after a deadly mix of shocking failures in a ‘severely dysfunctional’ maternity ward at Furness General Hospital in Barrow, Cumbria.
A combination of feuding medics, an obsession with “natural” births, and a close-knit group of midwives calling themselves “The Musketeers” contributed to a “troubling chain of events” that led to avoidable harm to mothers and babies.
The investigation covered incidents at the hospital between 2004 and 2013 and revealed a series of failures ‘at every level’ – from the maternity ward to those responsible for regulating and monitoring the trust that runs the ward.
The final report, published in 2015, denounced the clinical competence of staff, a “them and us” culture among midwives, midwives and pediatricians, and an overzealous pursuit of natural delivery “at all costs” by a small group of dominant midwives.
dr. Bill Kirkup, lead investigator of the East Kent probe, originally raised the alarm about NHS maternity care after his 2015 Morecambe Bay NHS Trust report warned other hospitals to take note of more scandals in the future
That historic report found 11 babies and one mother died after a deadly mix of shocking failures in a “severely dysfunctional” maternity ward at Furness General Hospital. The scandal only came to light thanks to the Joshua Titcombe family (pictured) who died nine days after his birth in 2008
It also suggested that when babies died, midwives conspired to cover up the deficiencies.
Concerns at the Trust were raised thanks to the Joshua Titcombe family’s campaign.
Joshua was just nine days old when he died in 2008 from an infection that should have been treated with antibiotics but didn’t, leading to a long fight for the truth by his family.
In his comments, Dr. Kirkup’s “zealous and courageous families” who had “permanently refused to accept what they were told” by hospital staff.
And prophetically, he said they were vital lessons from Morecambe Bay learned by other trusts to prevent similar tragedies in the future.
“It is vital that the lessons, which are now plainly seen, are learned and acted upon, not least by other trusts who must not believe ‘it couldn’t happen here,'” he said.
“If those lessons aren’t followed up, we’re destined to add back to the roster sooner or later.”
Shrewsbury and Telford
A scathing five-year investigation, published in March this year, revealed that 201 babies and nine mothers died needlessly during two decades of appalling care at the Shrewsbury and Telford Hospital NHS Trust.
The study examined cases involving 1,486 families, mostly from 2000 to 2019, and found that “repeated care mistakes” had resulted in injury to mothers or their babies.
Babies suffered skull fractures, broken bones or developed cerebral palsy after traumatic forceps deliveries, while others suffered oxygen starvation or life-changing brain injuries.
In one case, cleaners threw away vital information stored on post-it notes — with “tragic consequences for a newborn and her family.”
It also found that in some cases, mothers were blamed for their own deaths.
The East Kent review came the same year a scathing review from Shrewsbury and Telford NHS Trust found 201 babies and nine mothers to die needlessly
Donna Ockenden, the senior midwife behind the damning probe, ruled that the organization “hasn’t researched, hasn’t learned and hasn’t improved.”
She added: “This resulted in tragedies and life-changing incidents for so many of our families.”
Staff appeared to be afraid to speak out about mistakes because of the ‘culture of subversion and bullying’, while bosses ignored parents who expressed concern about the way they were treated.
There were issues with staffing levels, patient safety management, patient and family involvement in care and investigations, as well as complaint procedures.
Doctors also discouraged cesarean deliveries as part of a drive to push up so-called ‘natural’ birth rates, which Ms Ockenden said resulted in ‘many babies dying during birth or shortly afterwards’.
External health authorities failed to adequately investigate serious incidents where families themselves did not have access to assessments of their care.
Like Dr Kirkup in his research on Morecambe Bay, Ms Ockenden warned that shortcomings in Shrewsbury and Telford were not unique.
Ms Ockenden listed 15 ‘immediate and essential’ steps every NHS maternity ward should take, including better training and better communication with families.
She warned that pregnant women cannot give birth safely until her recommendations from the report are implemented.
University Hospitals of Nottingham
Findings of yet another NHS pregnancy scandal are likely to be published in the next 18 months.
Ms Ockenden, the midwife behind the damning report on Shrewsbury and Telford, is currently leading an investigation into reports of poor maternal and baby care at Nottingham University Hospitals NHS Trust.
Her appointment followed a response from parents over the Trust’s previous health assessment assessment, which critics feared was not truly independent.
The new investigation began in September and will examine events from April 2012 to the present.
Another major study into NHS maternity care is currently underway at Nottingham Nottingham University Hospitals. The final report is expected in March 2024
The trust, which manages 15 hospitals in the Midlands, is said to have died at least nine babies and three mothers in the past three years.
It had previously paid out millions of pounds on 30 baby deaths and 46 babies with brain damage.
The final copy of the report is expected to be published in March 2024, but could be extended depending on evidence received.