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East Kent maternity deaths: Babies may have survived with better care East Kent maternity deaths: Babies might have survived with better care
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Harry Richford would have survived but for failings by the hospitalHarry Richford would have survived but for failings by the hospital
Up to 45 babies may have survived if they had received better care at East Kent NHS Hospitals Trust, a damning independent review has found. Up to 45 babies might have survived if they had received better care at East Kent NHS Hospitals Trust, a damning independent review has found.
It found a "clear pattern" of "sub-optimal" care that led to significant harm and families were not listened to.It found a "clear pattern" of "sub-optimal" care that led to significant harm and families were not listened to.
The medical experts reviewed an 11-year period from 2009 at two hospitals in Margate and Ashford.The medical experts reviewed an 11-year period from 2009 at two hospitals in Margate and Ashford.
The trust, which previously said it was "determined to learn any lessons", has been heavily criticised by parents.The trust, which previously said it was "determined to learn any lessons", has been heavily criticised by parents.
The independent review, which was chaired by Dr Bill Kirkup CBE, added the trust had given the appearance of "covering up the scale and systemic nature" of its problems.The independent review, which was chaired by Dr Bill Kirkup CBE, added the trust had given the appearance of "covering up the scale and systemic nature" of its problems.
And it found that there was "no evidence to convince us that this cycle has ended".And it found that there was "no evidence to convince us that this cycle has ended".
The independent review was chaired by Dr Bill Kirkup CBE
Investigators said the trust wrongly took comfort from the fact most births at East Kent ended with no damage to mother or baby.Investigators said the trust wrongly took comfort from the fact most births at East Kent ended with no damage to mother or baby.
And they found harm was not just restricted to physical damage, and there was repeated lack of kindness and compassion even in the aftermath of injuries and deaths. They found harm was not just restricted to physical damage, and there was repeated lack of kindness and compassion even in the aftermath of injuries and deaths.
Dr Kirkup's team also found "gross failures" of team-working across the trust's maternity services, with some staff acting as if they were responsible for "separate fiefdoms, cultivating a culture of tribalism".Dr Kirkup's team also found "gross failures" of team-working across the trust's maternity services, with some staff acting as if they were responsible for "separate fiefdoms, cultivating a culture of tribalism".
"The dysfunctional working we have found between and within professional groups has been fundamental to the suboptimal care provided in both hospitals," the report said."The dysfunctional working we have found between and within professional groups has been fundamental to the suboptimal care provided in both hospitals," the report said.
Troubled maternity service still beset by problemsTroubled maternity service still beset by problems
Mothers felt blamed by medical staffMothers felt blamed by medical staff
Harry Richford's family's five-year fight for justiceHarry Richford's family's five-year fight for justice
A series of failings emerged during the inquest of Harry Richford, who died seven days after being born in 2017.A series of failings emerged during the inquest of Harry Richford, who died seven days after being born in 2017.
The hearing in January 2020 found Harry's death at The Queen Elizabeth the Queen Mother Hospital (QEQM) in Margate was "wholly avoidable".The hearing in January 2020 found Harry's death at The Queen Elizabeth the Queen Mother Hospital (QEQM) in Margate was "wholly avoidable".
The trust was fined £733,000 for failing to provide safe care and treatment for him and his mother Sarah Richford.
The Richfords have long campaigned for answers after saying their concerns were repeatedly brushed aside by hospital managers.
The trust has apologised for Harry's death, which it initially said was "expected". However it was not the first incident of its kind.The trust has apologised for Harry's death, which it initially said was "expected". However it was not the first incident of its kind.
Twin Harry Halligan spent a week in intensive care after failings with his deliveryTwin Harry Halligan spent a week in intensive care after failings with his delivery
Harry Halligan died in 2012 following mistakes during his delivery at the William Harvey Hospital in Ashford.Harry Halligan died in 2012 following mistakes during his delivery at the William Harvey Hospital in Ashford.
Afterwards, the trust was put into special measures by the Care Quality Commission, which rated its maternity services as "inadequate".Afterwards, the trust was put into special measures by the Care Quality Commission, which rated its maternity services as "inadequate".
Directives for improvement were made, but the trust failed to implement almost all the recommendations.Directives for improvement were made, but the trust failed to implement almost all the recommendations.
Harry Richford's family claim their baby might not have died if the trust had learned from the death of Harry Halligan, and have spent years demanding systemic change at East Kent's maternity units.Harry Richford's family claim their baby might not have died if the trust had learned from the death of Harry Halligan, and have spent years demanding systemic change at East Kent's maternity units.
Other parents said they felt they were blamed by the trust after they lost their babies. Speaking to reporters following the release of the report, Dr Kirkup said the most troubling aspects of his review were the attitude and behaviours of some trust staff towards families with legitimate complaints.
He called for change to be implemented at the trust as soon as possible but added it will take time.
Helen Gittos felt blamed by medical staff for her daughter's deathHelen Gittos felt blamed by medical staff for her daughter's death
Helen Gittos felt blamed by medical staff for her daughter's deathHelen Gittos felt blamed by medical staff for her daughter's death
The review examined the circumstances of maternity deaths at both the QEQM and the William Harvey. Dr Kirkup said 45 of the 65 baby deaths that occurred during the review period could have had a different outcome.
In an email to staff last month, trust chief executive Tracey Fletcher said the report would make "harrowing" reading and have a "profound" impact on families and colleagues. He said the scale of the failings at the trust was "deplorable and harrowing" and that there was anger among families he had met.
Dr Kirkup, who met with families affected during the probe, has led several reviews, including chairing the investigation of Morecambe Bay maternity services. A prominent theme which emerged during the review was the presence of "challenging personalities, big egos, huge egos", with one group dubbed "the A-team".
Speaking ahead of the report's publication, Dr Kirkup told BBC Radio 4's Today programme: "When I reported on Morecambe Bay maternity services in 2015, I did not imagine for one moment that I would be back in seven 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. An external assessor with wide NHS experience said the trust had the worst culture they had seen, while another said they had not encountered such behaviour anywhere else.
"This cannot go on. We have to address this in a different way. Dr Kirkup has previously led several reviews, including chairing the investigation of Morecambe Bay maternity services.
"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."
Nadine Dorries, the former minister for patient safety, announced in February 2020 that the review at East Kent would be held.Nadine Dorries, the former minister for patient safety, announced in February 2020 that the review at East Kent would be held.
The report was originally intended to be published last month, but was delayed following the death of Queen Elizabeth II.The report was originally intended to be published last month, but was delayed following the death of Queen Elizabeth II.
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