East Kent maternity inquiry to examine failings spanning more than a decade

Investigation findings will not be published until autumn of 2022

Harry Richford pictured with his parents Tom and Sarah shortly before his death in 2017 (Richford family)

An inquiry into dozens of baby deaths at an NHS trust will examine failings from “ward to board” covering a period of more than a decade, it has emerged.

The independent inquiry into poor maternity care at East Kent Hospitals University Trust published its terms of reference and scope for how it will carry out its work on Thursday.

The probe, led by Dr Bill Kirkup, was commissioned by the government after The Independent revealed more than 130 infants suffered brain injuries during birth at the trust over several years.

The scandal was exposed by the family of baby Harry Richford who died after a catalogue of errors by maternity staff in November 2017. A coroner ruled his death was the result of neglect and “wholly avoidable”.

Several other families have also spoken out over the deaths of their babies, with evidence emerging the trust’s managers were warned about safety concerns but failed to take action.

In October, the Care Quality Commission (CQC) said it intended to prosecute the trust over the death of Harry Richford.

It is understood that since the inquiry was launched, a significant number of families have come forward with concerns but the inquiry has refused to say what the total number of cases is.

In a written statement to parliament on Thursday, patient safety minister Nadine Dorries announced the inquiry’s terms of reference and scope for the investigation.

She said: “We take the patient safety concerns at East Kent maternity services very seriously. The independent investigation will provide an independent assessment of what has happened with East Kent maternity and neonatal services and identify lessons and conclusions.”

She confirmed it will look at the safety of services from 2009 to 2020 and will present a final report by the autumn of 2022.

The terms of reference state the inquiry will look at what happened in each of the individual cases which will be independently examined, how the trust responded to individual cases and how the organisation responded to warning signs over its maternity services. This will include how the trust engaged with regulators and other NHS bodies.

It pledged to assess the governance arrangements “from ward to board” adding it would “draw conclusions as to the adequacy of the actions taken at the time by the trust and the wider system. Taking account of improvements and changes made, the independent investigation will aim to provide lessons helpful to East Kent but also to share nationally to improve maternity services across the country”.

It will also look at the response of NHS bodies and regulators to events at the trust.

Cases to be included will be where there was a preventable death, a concern the death may have been avoidable or where there was a damaging outcome to mother or baby or where the case may help shed light on how services were run.

Helen Gittos, whose baby Harriet died in August 2014 when she was eight days old, told The Independent she welcomed the proposed plans.

“It’s great to see how comprehensive they are and to see that they are putting the families’ experiences at the heart of it as well as investigating the way management responded to alerts that there were problems.”

She said families were aware that staff on the trust’s maternity unit were working in a wider context and that the role played by senior managers and other bodies outside the trust must be examined.

“It is another amazing opportunity to try and change the landscape and get some meaningful change.”

A statement on the inquiry website said: “We are very grateful to those families who have come forward and confirmed their wish to have their cases considered as part of the investigation.

“The investigation commenced on 23 April 2020 and a number of families came forward at that stage. On 1 October 2020, as chair of the independent panel, Dr Kirkup issued an invitation for any new families to let us know if they too would like to participate in the investigation.

“As a result, an increased number of families have been included in the work of the investigation and sessions are underway enabling panel members to hear directly from family members.

“The focus is therefore now shifting from receiving new cases to meeting the families who have come forward and to analyse the various records and completing the remaining stages of the investigation.”

The East Kent trust has said it has made changes to its maternity service as a result of concerns including a 24 hour consultant presence at the William Harvey Hospital, in Ashford and opening a new triage unit for maternity which will open in March.

Susan Acott, chief executive of East Kent Hospitals, said: “We wholeheartedly apologise to those families we could have done things differently for and we are grateful to everyone who has shared their experience of our maternity services.

“We are continuing to support the investigation team and working with HSIB and our partners, we have made improvements to our service, including by increasing staffing levels, launching a continuity of carer home birth team and building a dedicated maternity triage unit.”