East Kent: Maternity scandal trust still had higher-than-average deaths last year, report says

East Kent hospitals failed to act on key safety recommendations, new report reveals

Harry Richford died as a result of neglect and avoidable errors at East Kent Hospitals Trust

A hospital being investigated over poor maternity care still had an above average number of babies dying as recently as last year, it has emerged.

East Kent Hospitals University Trust has also admitted it took action on only two out of 23 recommendations made by a damning 2016 review of maternity services by the Royal College of Obstetricians and Gynaecologists (RCOG).

Earlier this year The Independent revealed there had been dozens of deaths at East Kent Hospitals Trust with more than 130 babies suffering brain damage as a result of being starved of oxygen during their birth over a four-year period.

In a report to the trust’s July board meeting the head of a special committee, set up in the wake of the inquest into the death of baby Harry Richford in January, said the trust was now facing an external review of its death rates.

Committee chair Des Holden, medical director of Kent Surrey Sussex Academic Health Science Network, said a review of deaths showed “the number of still births has fallen” and was now below the average for similarly sized maternity units.

He added: “But the number of babies born alive and subsequently dying in 2019 would put EKHUFT above the average.” He said Imperial College London’s Neonatal Research Group had agreed to carry out a review of mortality for the trust.

Concerns about the safety of maternity care at the trust’s Queen Elizabeth, the Queen Mother, Hospital in Thanet prompted a review by the RCOG in 2016 which found a group of consultants who repeatedly refused to work evenings and weekends were leaving less experienced staff on their own. It also highlighted a poor safety culture with staff unwilling to raise concerns.

These failings were repeated in the case of Harry Richford more than a year later. An inquest into his death in January this year ruled he died as a result of neglect.

The Care Quality Commission is investigating the trust and considering a criminal prosecution over its failure to act on known safety risks.

Dr Holden’s committee found that while there had been 23 recommendations made there was only “sufficient evidence” to say that two had been met. There was partial evidence for 11. For 10 recommendations there was either no evidence of delivering the measures, or available evidence suggested it had not been delivered.

However, Dr Holden said all the recommendations to the trust made by the coroner in the Harry Richford case in January had either now been completed or were in the process of being implemented.

Derek Richford, Harry’s grandfather, said on behalf of the family: “We are saddened and shocked to find that over four years after the RCOG found fundamental systemic failings and made 23 recommendations, only two have been completed. It is not good enough for them to now say ‘leadership has changed’. The main board must take responsibility and be held to account.”

A spokesman for East Kent Hospitals University Foundation Trust said: “We are determined to provide an excellent standard of care to every mother and child who uses our maternity service, and we will not rest until we, the public and our regulators are confident we are doing so.

“Therefore, as part of our response when concerns were raised about the safety of our maternity services in January this year, we committed to scrutinising robustly what had been done in response to the RCOG report since 2016, and also whether the trust holds sufficient evidence of completion for each of the 23 recommendations.

“We set up a board learning and review committee, chaired by an external senior clinician, to oversee this work. This was one element of the committee’s remit to objectively and comprehensively examine the trust’s governance of maternity services.

“The findings from the review have been published today.

“Of the 23 recommendations, the review considered that 13 had been met or partially met, but that for 10 of the recommendations, there was insufficient evidence of fully delivering the recommendation.

“All the recommendations from the RCOG report, the CQC report and from elsewhere are being incorporated into a single integrated improvement programme for maternity. The board will have full oversight of this programme."