At least seven preventable baby deaths may have occurred at one of the largest groups of hospitals in England since 2016, a BBC investigation has found.
Significant concerns have been raised about maternity services at the trust.
The heartbroken father of one baby who was stillborn said “we have to live with it, for the rest of our lives… they’ve probably forgotten who we are”.
East Kent NHS Foundation Trust has apologised, saying it has “not always provided the right standard of care”.
The trust consists of five hospitals and community clinics and almost 7,000 babies are born there each year.
The trust is likely to be criticised on Friday at the conclusion of an inquest into the death of baby Harry Richford. He was born in November 2017 at the Queen Elizabeth the Queen Mother (QEQM) Hospital in Margate, but died seven days later after complications with his delivery and aftercare.
- Harry Richford born in ‘room full of panicking people’
- Inquest hears doctor was ‘utterly out of his depth’
At the start of the inquest, the trust apologised for the care Harry received.
The BBC has uncovered a series of other preventable deaths and incidents of poor maternity care before and after Harry’s case.
Archie Powell died on 14 February 2019, aged four days. The twin brother of Evalene, he became ill shortly after birth. Medics initially treated him for a bowel problem but despite showing all the symptoms, failed to spot he was actually suffering from a common infection, group B streptococcus.
The delay in treating Archie’s infection caused severe brain damage, and he died after being transferred to a neo-natal unit in London.
An internal investigation by the trust found his death “potentially avoidable”.
“We’ve just got this void in our lives where he should be,” says Archie’s mother, Dawn.
Tallulah-Rai Edwards died on 28 January 2019, stillborn.
In the 36th week of pregnancy, her mother became anxious about the baby’s slowed movement and went to hospital for monitoring.
But despite struggling to get a good heart-rate reading on the cardiotocography (CTG) machine, midwives sent her home, saying they were satisfied with what they recorded.
Two days later, the baby was found to have died when her mother returned to the hospital, insisting on further monitoring.
An internal investigation found: “The CTG should have been continued for longer and an ultrasound arranged.”
Tallulah-Rai’s father, Nick, is heartbroken: “We have to live with it, for the rest of our lives. They don’t. They’ve probably forgotten who we are now.”
Hallie-Rae Leek died on 7 April 2017, aged four days.
The midwife struggled to find a heart-rate and by the time Hallie-Rae was born, she was in a poor condition. It took 22 minutes to resuscitate her, but irreparable damage had been done.
The trust accepted the death was preventable and apologised.
“If she’d been born earlier, she would be here today, she’d have survived. It makes me feel angry that there’s so many cases of negligence, that babies are suffering and dying,” says Hallie-Rae’s mother Becca.
Archie Batten died on 1 September 2019, shortly after birth.
When his mother called the hospital to say she was in labour, she was told the QEQM maternity unit was closed and she should drive herself to the trust’s other hospital, the William Harvey in Ashford, about 38 miles away.
This was not feasible and midwives were sent to her home, but struggled to deliver the baby and she was transferred by ambulance to QEQM where her son died. Archie’s inquest is scheduled for March.
‘Concerns over working culture’
There were also two stillbirths in 2016:
- In March that year, the unit failed to recognise a baby boy was small for his dates, did not act on suspicious CTG readings and failed to deliver the baby promptly.
- And in June, risk factors were again not identified, the CTG was not properly monitored and a baby girl died.
“The trust admitted in both of those cases, that had proper care been given in term of the obstetrics and midwifery care, then those children would have survived,” says Emmalene Bushnell, from Leigh Day solicitors, who acted for both families.
This is not the first time concerns have been raised about maternity services at an NHS hospital in recent years.
News that mistakes have been made in Kent which may have led to babies dying comes after scandals at Morecambe Bay and Shrewsbury and Telford.
But how safe is NHS care? Research shows out of 700,000 births a year in England and Wales around 5,000 babies are stillborn or die before they are a month old.
This is about a fifth lower than it was a decade ago but remains higher than in a number of other Western countries.
Many are expected because of unavoidable complications. But every year there are around 1,000 unexpected deaths and serious brain injuries.
The situation has prompted action. In 2015 the government set a target of halving the rate of stillbirths, baby deaths and brain injury by 2030. The target has since been brought forward to 2025.
To help, the Healthcare Safety Investigations Branch has been tasked with investigating all cases of potentially avoidable harm rather than leaving it to hospitals themselves.
All this has been welcomed. However, unions argue one of the biggest problems – a lack of staff – has still not been solved.
The trust has struggled to improve maternity care for years, despite repeatedly being made aware of the problems.
In 2015, the medical director asked experts from the Royal College of Obstetricians and Gynaecologists to review maternity care, amid “concerns over the working culture”.
Their review, seen by the BBC, found poor team working in the unit, a number of consultants operating as they saw fit, a lack of performance management of the consultant body and out of date clinical guidelines.
It highlights consultants who:
- failed to carry out labour ward rounds, review women, make plans of care or attend out of hours when requested
- rarely attended CTG training
- were reported “as doing their own thing rather than follow guidelines”
Staff told the review they believed:
- maternity services were not a priority at Board level
- there was little point in raising concerns as no action would be taken by the trust
The trust was placed into special measures in 2014 following an inspection by the Care Quality Commission which rated its care, including maternity services, as inadequate.
Subsequent CQC reports have rated it as Requires Improvement.
The trust’s extended perinatal mortality rate, the total of stillbirths and those babies who die within 28 days of being born, has been consistently higher than the UK average for every year between 2014 and 2017.
And in 2017, the last year for which figures are available, it was the highest in the country of trusts offering comparable maternity services.
In a lengthy statement to the BBC, the trust did not address any of the cases we highlighted.
Instead it said: “We have been making changes to improve our maternity service for a number of years.
“Every baby and every family is important to us. We recognise that we need to improve the speed of change.
“We express our heartfelt condolences to every family that has lost a loved one and we wholeheartedly apologise to families for whom we could have done things differently.”
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