Dozens of babies and mothers died or were injured during childbirth because of repeated failings in maternity care at a major NHS trust, a damning report has found.
Dr Bill Kirkup, who led the investigation, said his findings into substandard care at the East Kent trust between 2009 and 2020 were “shocking and uncomfortable” and had a catastrophic impact on families.
Kirkup’s scathing report is the second this year alone, and the third since 2015, to expose what he called “embedded, deep-rooted problems” in the way the health service looks after pregnant women and their babies.
His almost three-year long inquiry identified an array of serious problems with maternity services at the trust’s William Harvey hospital in Ashford and Queen Elizabeth the Queen Mother hospital in Margate.
“What has happened in East Kent is deplorable and harrowing,” he said at the report’s launch on Wednesday. A report in March found similar problems at the Shrewsbury and Telford trust.
Babies and their mothers suffered “significant harm” at East Kent as a result of “suboptimal care”, which was the result of poor decision-making by staff and infighting within and between midwives and obstetricians, the report said. The trust allowed huge tensions within its maternity workforce to continue, got rid of managers who tried to address the problems – and in some cases even blamed mothers for the death of their child.
Kirkup castigated the trust and its leadership during the 11 years in question for covering up the extent of the harm done to women and babies. That was part of a culture of “deflection and denial” which was a “cruel practice” that exacerbated the trauma families were experiencing.
In almost half the 202 cases of death and harm Kirkup and his team looked into, the mother or baby would have had a different outcome if trust staff had followed nationally accepted standards of care.
For example, of the 65 baby deaths they investigated, 45 of the newborns might have lived if they had had what medical bodies and regulators say are the standards of care all pregnant women and their babies should always receive.
Twelve of 17 newborns who suffered brain damage may not have done so if they had been looked after properly. Similarly, 23 of 32 mothers would not have suffered injury or died while giving birth if they had received good care.
Kirkup’s 192-page report detailed some horrific practices and behaviours, and a dangerous culture, at the two hospitals’ maternity units, including:
Squabbling between midwives, obstetricians, paediatricians and other groups of staff which involved “factionalism, lack of mutual trust and … bullying”.
Junior obstetricians and midwives often got the blame for errors committed by more senior colleagues.
Midwives not part of the midwifery team’s “A-team” were given the highest-risk mothers to care for – “a downright dangerous practice”.
Mothers were given too little pain relief, ignored when they sought to raise concerns and spoken to with a lack of compassion, with one who had lost her baby told “it’s God’s will; God only takes the babies that he wants to take”.
He also found that trust bosses:
Missed eight opportunities during 2009-20 to acknowledge the extent of problems and solve them.
Saw the trust as a “victim” of external factors that were causing its poor maternity care, such as lack of staff and its coastal location, and did not see that the real causes were internal and involved “failures in team-working, professionalism, compassion and listening”.
Compounded families’ suffering by not being open and honest.
The report tells NHS bosses, ministers and heath professionals that the dangerous dysfunction at East Kent, allied to other maternity care scandals, means “it is too late to pretend that this is just another one-off, isolated failure, a freak event that ‘will never happen again’.”
Maternity services across the NHS need to take urgent action to tackle “longstanding issues [that have] become deeply embedded and difficult to change”. To improve patient safety, hospitals need to do much more to identify much faster problems that arise in maternity units, ensure better team-working between midwives and obstetricians, make care kinder and more compassionate and be honest when mistakes are made. If they do not, other scandals like East Kent are inevitable, the report says.
Birte Harlev-Lam, the executive director midwife at the Royal College of Midwives, said too many maternity units displayed “toxic cultures that put women and babies at risk”.
Kirkup, an obstetrician and expert in patient safety, undertook an inquiry in 2015 into similar problems into poor maternity care at the Morecambe Bay trust in Cumbria. “I did not imagine that I would be back reporting on a similar set of circumstances seven years later,” he said.
A host of policy changes since 2015 intended to improve maternity care had not achieved their goal of making it safe, he said.
Kirkup vindicated claims by some bereaved parents that the trust had been guilty of “victim blaming” mothers for their children’s deaths.
Kelli Rudolph and Dunstan Lowe, whose daughter Celandine died at five days old, said: “Doctors sought to blame Kelli for Celandine’s death. This victim-blaming was the first in a long line of interactions with those in the trust who sought to delay, deflect and deny our search for the truth about what happened to our baby.
“In isolation, these tactics traumatised us after the tragedy of our daughter’s death. But when seen in the light of 10 years of failures, they signal a concerted effort to cover up the trust’s responsibility for what happened to Celandine and the many others who lost their lives due to failures in clinical judgment.”
Helen Gittos and Andy Hudson, whose full-term, healthy daughter Harriet died in 2014, said: “Too often during pregnancy, in labour and afterwards rather than being listened to, we were treated dismissively, contemptuously and without a desire for understanding. It is hard enough to come to terms with the death of a child; it is even harder when you are implicitly blamed for what happened.”
Jacqueline Dunkley-Bent and Matthew Jolly, NHS England’s chief midwifery officer and national clinical director for maternity care, said that as a result of Kirkup’s findings “we will work closely with trusts in England and our partners to make every necessary improvement and ensure that all or services are as safe as possible for mothers, babies and their families”.
Tracey Fletcher, the trust’s chief executive, said: “I want to say sorry and apologise unreservedly for the harm and suffering that has been experienced by the women and babies who were within our care. These families came to us expecting that we would care for them safely, and we failed them.”
