‘How many more must die?’: Heartbroken parents are left outraged by needless deaths of 45 newborn babies in another hospital maternity scandal
- Review into serious failings at East Kent Hospital Trust were published yesterday
- Inquiry, led by Dr Bill Kirkup, looked at more than 200 cases dating back to 2009
- Report described how at least 45 babies died unnecessarily due to poor care
- It said there were midwives who were ‘bullying and dismissive’ towards mothers
Devastated families were left asking ‘how many more babies must die’ following the latest ‘catastrophic’ maternity scandal to shame our health service.
A damning report yesterday exposed the outrage that at least 45 babies died unnecessarily due to ‘deep-rooted’ failures in care at East Kent Hospitals NHS Trust.
In total, 97 babies and mothers came to significant harm over 11 years due to ‘deplorable’ care by maternity staff.
Investigators had no doubt the numbers were ‘minimum estimates’ and said a lack of meaningful action meant it is likely similar incidents are happening elsewhere.
Dr Bill Kirkup, who led the investigation, warned that such incidents can no longer be seen as a ‘one-off’ and called for a new national system to ‘break the cycle’ of maternity scandals.
He called for a ‘public service accountability law’ to be introduced so organisations can be prosecuted if they stage cover-ups in future tragedies.
Last night, grieving parents said this had to be the last maternity scandal to hit the NHS, while asking why there had not been more of an outcry about ‘two full classrooms’ of children who never came home. Dr Kelli Rudolph, who lost daughter Celandine when she was five days old in 2016, said this has to be ‘the end point’.
Bex Walton, who lost her son Tommy when he was two days old, said: ‘Sorry is not good enough’
The mother said she would ‘never be able to forgive’ after loosing her son Tommy (pictured)
Danielle Clark suffered a traumatic birth with her son Noah – now nine – and felt her concerns at at East Kent Hospitals NHS Trust were dismissed
The mother said: ‘Things have got to change. Babies are dying just through bad care and pure neglect’ (pictured: her son Noah when he was just hours old)
She said: ‘If in this period of time, a serial killer had killed 45 babies it would be in the headlines from here until the ends of the earth.
‘But 45 babies are dead. It’s one thing to read that, but to sit there and [hear they were] avoidable deaths. What does 45 children look like in a classroom in a school? It’s two full classrooms.’
Danielle Clark suffered a traumatic birth with her son Noah – now nine – and felt her concerns were dismissed because she was a first-time mother. She said: ‘People need to be held accountable. Things have got to change. Babies are dying just through bad care and pure neglect.’
And Bex Walton, whose son Tommy died in 2020, two days after being born at the William Harvey Hospital in Ashford, said: ‘Sorry is not good enough.
‘I will never be able to forgive.’
The harrowing 182-page report was severely critical of the staff who presided over the poor care at the Queen Elizabeth The Queen Mother Hospital (QEQM) in Margate and the William Harvey Hospital between 2009 to 2020.
It described a ‘culture of tribalism’, which included midwives who were ‘bullying and dismissive’ towards mothers.
One woman whose baby had died was told by a member of staff: ‘It’s God’s will; God only takes the babies that he wants to take.’
Another, named only as C, was left bleeding after a traumatic delivery with her family told staff ‘are all in the staffroom having a cup of tea to recover’. The woman’s baby died the following day.
The harrowing 182-page report was severely critical of the staff who presided over the poor care at the Queen Elizabeth The Queen Mother Hospital (QEQM) (pictured) in Margate and the William Harvey Hospital between 2009 to 2020
The report described how maternity services suffered as consultants ‘expected junior staff and locum doctors to manage clinical problems themselves, discouraged escalation, and on occasion refused to attend out of hours’.
It recorded 97 incidents where mothers or babies either died or suffered injuries or disabilities as a result of poor treatment.
These included 45 cases where babies died – 12 of brain damage – and 23 incidents of mothers dying or suffering injuries.
In a letter to Health Secretary Therese Coffey and NHS chief executive Amanda Pritchard, Dr Kirkup said the report must be a catalyst for tackling ‘embedded, deep-rooted problems’.
He wrote: ‘It is too late to pretend that this is just another one-off, isolated failure, a freak event that will ‘never happen again’.
‘Since the report of the Morecambe Bay investigation in 2015, maternity services have been the subject of more significant policy initiatives than any other service.
‘Yet, since then, there have been major service failures in Shrewsbury and Telford, in East Kent, and (it seems) in Nottingham. If we do not begin to tackle this differently, there will be more.’
In April, Donna Ockenden, who led a report into the worst maternity scandal – in which 201 babies and nine mothers died at Shrewsbury and Telford hospitals – called for sweeping reforms.
Now Dr Kirkup, an obstetrician, said it should be a criminal offence for NHS staff and public sector workers to lie to members of the public and urged a ‘maternity signalling system’ to be set up within months to monitor data and flag abnormally high rates of baby deaths at NHS trusts.
Miss Coffey had been expected to respond to the report in Parliament but remained silent.
Health minister Caroline Johnson apologised to families and said the NHS was ‘committed to preventing families from going through the same pain in future’.
The National Childbirth Trust said: ‘The devastating truth is that this report is not a one-off.
Birte Harlev-Lam, of the Royal College of Midwives, said: ‘We cannot have review after review, report after report, and nothing fundamentally changes.’
Jacqueline Dunkley-Bent, chief midwifery officer at NHS England, said: ‘It is clear that there have been severe failings in the care they received, when they should have been protected and cared for by our services.’
Harry, Archie, Daisy, Harriet, Jessica… Too many names. Too much loss
By Beth Hale, Kate Pickles and Mary O’Connor
Seven years ago, Bill Kirkup published a report into what was then one of the most distressing maternity scandals to have struck the NHS.
In a harrowing 205-page Morecambe Bay review, he wrote of a ‘distressing chain of events that began with serious failures of clinical care’, the result of which was ‘avoidable harm to mothers and babies, including tragic and unnecessary deaths’.
Who could have imagined the spiralling catalogue of scandals that would follow. Morecambe Bay led into Shrewsbury and Telford NHS Trust in Shropshire; Nottingham still looms on the horizon – each fresh outrage laying bare a litany of tragedy, shattering the confidence of families in maternity provision in the UK and eroding morale within a beleaguered profession.
And yesterday, there was Bill Kirkup again. Delivering words in East Kent that sounded heartbreakingly familiar. ‘When I reported on Morecambe Bay maternity services in 2015, I did not imagine that I would be back reporting on a similar set of circumstances seven years later,’ he said. ‘It is too late to pretend that this is just another one-off, isolated failure, a freak event that “will never happen again”.’
Among those hoping his words will, this time, mark a turning point for maternity care are the families of those whose children and grandchildren’s lives were cut short – sometimes before birth, sometimes shortly afterwards – when they could have been saved.
There are far too many of them. In East Kent alone, Kirkup’s review found that the ‘outcome’ (put less clinically, that’s life or death) could have been different for 45 out of 65 baby deaths.
Sarah and Tom Richford with their son Harry who died seven days after he was born in November 2017 at the QEQM
Among them was Harry Richford, whose death at William Harvey hospital – a week after he was delivered at the Queen Elizabeth The Queen Mother Hospital (QEQM) in November 2017 – triggered the inquiry.
Harry died a week after his chaotic birth, which involved a catalogue of errors by medical staff that were exposed only through the determined efforts of the little boy’s family.
Parents Sarah and Tom, both teachers, had been excitedly planning the arrival of their much-wanted child. After a ‘textbook’ pregnancy, Sarah had an emergency caesarean section which was performed too late and by an inexperienced locum who had not been fully assessed by the trust.
Harry was born silent and limp, and there was a delay in resuscitating him. He died seven days later from irreversible brain damage and yet, initially, East Kent refused to refer his death to the coroner, claiming it was ‘expected’.
It was his grandfather, Derek Richford, now a passionate campaigner for transparency and improvements in maternity care, who – fearing a cover-up – did so in March 2018. The three-week inquest in January 2020 exposed serious failings at the trust and ruled that Harry’s death was ‘wholly avoidable’ and amounted to ‘neglect’.
There followed a landmark decision by the Care Quality Commission (CQC) to prosecute the NHS trust for failing to provide safe care and treatment. Meanwhile, other grieving families came forward with devastating tales of potentially avoidable tragedies.
Dr Bill Kirkup, who led the investigation, warned that such incidents can no longer be seen as a ‘one-off’ and called for a new national system to ‘break the cycle’ of maternity scandals
Archie Batten, Archie Powell, Harriet Gittos, Reid Shaw. Too many names. Too much loss.
Iris Crowhurst, like so many other mothers, still grieves the loss of her daughter Jessica, who would be 11 if events had unfolded differently.
Iris was thrilled to discover she was expecting a second child in 2011. At the time she was running several of dental practices, while juggling looking after her four-year-old daughter Felicity.
Jessica’s arrival would complete the family, but it was never to be.
After a pregnancy made gruelling by sickness, a series of failures to correctly monitor the mother culminated in a harrowing stillbirth.
Iris, 45, who still lives in Ramsgate and now works in security after her business crumbled under the weight of her loss, says: ‘It was a catalogue of errors. It wasn’t just one.’
At 30 weeks pregnant, Iris was told her unborn child was much larger than expected and she would need to be induced. But for reasons she cannot fathom, her gestational diabetes – high blood sugar which develops during pregnancy, and which can cause a baby to grow larger than usual – went undiagnosed and just four weeks later, a consultant told her: ‘Don’t worry, your baby is large but no more scans, no nothing.’
Mothers are convinced that failures in treatment at the QEQM hospital led to the death of their children
‘We got to 39 weeks and I was huge and my blood pressure was through the roof,’ says Iris. ‘I went to the hospital a few times to be checked and they deemed her to be okay. But I later found out there were signs she was in distress.’
Worse was to come in her final desperate visit to hospital. Inexplicably, midwives mistook Iris’s heartbeat for that of her unborn child and sent her home. ‘She wasn’t alive, she had died at four o’clock in the afternoon, which they knew when they looked back at the trace [from the monitor Iris had to wear], but I was sent home,’ Iris says quietly.
In the ensuing operation to deliver Jessica, Iris suffered a devastating haemorrhage in which her partner Andy feared he was losing her too.
When she came around she was in a tiny room at the end of a corridor where she could hear medical staff talking about keeping her away from new mothers on the maternity unit so she didn’t ‘upset them’.
So harrowing was the experience, Iris didn’t even hold her child; she felt it would be just too painful. ‘If I had held her, I didn’t know how I would be able to give her back.’
Iris battled two years of terrible health, a break-up with her partner and her business crumbling before being diagnosed with the auto-immune disorder Graves’ disease. Last year, she was diagnosed with breast cancer and is convinced it is her body’s response to the strain of losing Jessica. Now she runs a small charity helping other bereaved families. The open wounds of loss have healed, but the deeper ones – and the anger at how she and others were treated – remain.
Harder still is the stark fact so many have to bear. ‘It was entirely avoidable,’ she says. ‘If I had been induced she would have lived, even on that last day there was a chance for her to survive.’
Thoughts of what might have been haunt so many parents.
Emma Robinson, 27, is convinced that failures in her treatment at the QEQM hospital led to her daughter Daisy’s death at just an hour old in 2014. In yesterday’s long-awaited report, Bill Kirkup says: ‘An over-riding 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.’
Emma, a trainee nurse and mother-of-three, feels she was stereotyped as a young mother, whose concerns were dismissed by unsympathetic staff.
After a straightforward early pregnancy, it was in her final trimester that she found herself making repeat visits to hospital with issues such as swelling and high blood pressure, but says she was dismissed by nurses, who told her ‘not to be silly’.
Emma Robinson believes failure in care contributed to the death of her daughter Daisy. An inquest recorded an open verdict, with the cause put down as sudden infant death
She was scheduled to be induced at 42 weeks, but at 41 weeks, suffering swelling, itchy skin and migraines, she returned to hospital, where despite tests revealing she had high blood pressure and protein in her urine – classic symptoms of pre-eclampsia, which can cause serious complications for both mother and baby and requires careful monitoring – she was sent home.
Her designated induction day was marred by more worrying warning signs – elevated blood pressure and meconium in the waters (this is a baby’s first faeces, and can be a sign of distress).
Daisy’s joyful arrival at 8lb 2oz was heartbreakingly brief.
‘She came out crying and fed on me, passed a poo and we had a cuddle,’ says Emma. ‘Then they went out of the room for a bit, did what they had to do and stitched me up and then they came to grab Daisy. But when they did, they ran out the room.
‘They were trying to resuscitate her for way over an hour.’
Emma needed further treatment to stabilise her blood pressure, meaning she had to stay in hospital while trying to process what had happened.
‘They left me in that ward until 11pm, listening to everybody else have their babies,’ she says.
A subsequent inquest recorded an open verdict, with the cause put down as sudden infant death. But Emma believes failures in her care contributed. ‘I was made to feel like it was just one of those things, that people lose their babies. I was told “babies die” and I was made to feel like there was no blame. But Daisy should still be here now,’ she says.
Families caught up in the scandal report a familiar refrain: Everything is okay, don’t worry. Until, that is, it was too late.
Shelley Russell, 41, was repeatedly told not to worry during her high-risk pregnancy with a longed-for third child in 2019.
After being told she had a blocked fallopian tube in July 2017, she had lost hope, but fell pregnant with her miracle baby after 18 months of trying.
When midwives first remarked on her daughter’s rapid heart rate, they told Shelley and her partner Nicholas (from whom she has since split) that their little girl was destined to be ‘an athlete’.
Tracey Fletcher, Chief Executive of East Kent Hospitals providing a statement following the publishing of Dr Bill Kirkup’s report into failings in maternity care and treatment of mothers and babies at East Kent Hospitals University NHS Foundation Trust
Shelley, from Dover, had her first inkling something wasn’t right at 36 weeks pregnant when she woke and realised baby Tallulah-Rai wasn’t moving as much as normal. She phoned her midwife and was told to go to Buckland hospital for a CTG (cardiotocography scan) to monitor the baby’s heart rate. A student midwife and a more senior midwife were involved in a protracted process of trying to detect the heart rate, culminating in the senior midwife signing off on the reading.
‘She came in, looked at the monitor, said “Are you happy?”. I said “If you are happy, I am happy”. That was it, off I went. She said if anything changes come back. But the next day, nothing had changed. Then the following day I remember waking up and feeling no movement whatsoever.’
Shelley and Nicholas returned to hospital, only to have their worst fears confirmed – their baby had died. Following a C-section delivery, a post-mortem examination revealed Tallulah-Rai had died of oxygen deficiency.
Now, in the process of taking legal action against the trust – it has denied liability in her case – not a day goes by when she doesn’t think of her daughter and what might have been.
Shelley was not in Kent for the delivery of the report, but on holiday in Dorset. Tallulah-Rai’s ashes, in a box decorated with Sleeping Beauty and her name, were beside her as they are every night. ‘After she was born I spent two days and one night with her and I thank my lucky stars for that time.’
For all she has been through, her feelings about the care she received tell two different tales of maternity provision.
‘I remember asking a midwife to look after Tallulah-Rai while I went to the toilet. As I walked back down the corridor, I heard singing, and there was the midwife holding Tallulah-Rai’s body and singing to her. I had three midwives during that time and they were amazing. I experienced the best and the worst of care.’
And therein lies one of the most bitter twists in scandal after scandal sweeping maternity provision. The best can so often be lost under the weight of the worst.
From insolent staff to bosses in denial, probe lays bare baby ward failures
By Kate Pickles Health Editor
The independent inquiry into maternity services at East Kent Hospitals University NHS Foundation Trust heard ‘harrowing’ accounts from families. Its excoriating report found:
Staff were at the heart of many of the failures. There was ‘a clear pattern’ of staff providing suboptimal clinical care that led to significant harm, failing to listen to families, and acting in ways which made families’ experience unacceptably and distressingly poor.
Families did not just suffer physical harm, with the ‘equally disturbing effects of the repeated lack of kindness and compassion’ by some staff.
LACK OF PROFESSIONALISM
There was a repeated lack of professionalism, where mothers and babies were not put first and often blamed when something went wrong. Staff often put their own needs ahead of the mothers and babies they treated. Some staff were disrespectful and disparaging towards colleagues in front of pregnant women, who would then lose confidence in services as a result. Others sought to deflect responsibility when something had gone wrong, with some mothers blamed for their own misfortune.
A woman admitted to hospital to stabilise her type 1 diabetes pointed out to antenatal ward staff that they were not adjusting her insulin correctly. She was told that ‘we’re midwives not nurses and we don’t deal with diabetes… it’s not our issue and you don’t fit in our box’.
Midwives who were not part of the favoured in-group or ‘A team’ were sometimes assigned to the highest-risk mothers and challenged to deliver babies with no intervention. This was described as ‘a downright dangerous practice’.
LACK OF COMPASSION
The report found many ‘shocking’ examples of uncompassionate care. A woman who asked for additional information on her condition during an antenatal check was told to look on Google. A mother who asked why an additional attempt at forceps delivery was to be made, was brusquely told that it was ‘in case of death’.
Women who said their spinal or epidural analgesia was not effective and they were in pain, were ignored or disbelieved, with one saying ‘they didn’t listen… they carried on, obviously, to cut me open. I could feel it all’.
FAILURES OF TEAMWORK
Gross failures of teamworking across maternity services were found, with problems between the midwives, obstetricians, paediatricians and other professionals involved. Some staff ‘acted as if they were responsible for separate fiefdoms, cultivating a culture of tribalism’.
Divisions among the midwives, including bullying, was to such an extent that the maternity services were not safe.
Some obstetric consultants expected junior staff and locum doctors to manage clinical problems themselves, discouraged escalation, and on occasion refused to attend out of hours.
The report found clear instances where poor teamwork hindered the ability to recognise developing problems.
It said the dysfunctional working between and within professional groups was fundamental to the suboptimal care provided.
CULTURE OF DENIAL
Senior managers and the trust board knew about problems but put professional reputation ahead of acknowledging the scale of the issues. There was a culture of ‘deflection and denial’ when families sought answers over substandard care. Although no evidence of a conscious conspiracy was found, ‘the effect of these behaviours was to cover up the truth’.
The trust focused on ‘reputation management’ and would often put incidents down to individual clinical error, usually on the part of more junior staff, or to difficulties with locum staff. There was a failure to challenge poor behaviour among midwives and consultants, with some staff left in tears, being shouted at and having things thrown at them. The trust did ‘little to change the poor working culture; instead, it tolerated bad behaviour’.
WHAT ABOUT REGULATORS?
Since 2010, the trust has had the involvement of at least ten external bodies, including the Royal College of Midwives, NHS England, regional managers and the Care Quality Commission.
The inquiry criticised external bodies for failing to take proper action, with numerous missed opportunities dating back to at least 2010. Investigators described ‘a bewildering array of regulatory and supervisory bodies’, but the system as a whole failed to identify the shortcomings early enough to ensure real improvement. Dr Bill Kirkup, chairman of the independent inquiry, said the East Kent report was ‘simply the latest to focus on failings in an individual NHS trust’ with similar harrowing practices dating back to the 1960s, and he called for urgent change.
The obstetrician wants it to become a criminal offence for NHS staff and public sector workers to lie to the public. Dr Kirkup also called for a national ‘maternity signalling system’ to monitor data from all NHS trusts for abnormally high rates of baby deaths. The report identified four areas where urgent action is needed within the NHS: better identifying poorly performing hospitals, ensuring care is given with compassion and kindness, better teamworking, and responding to issues with honesty.
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