Repeated and serious failings in care of babies and mothers led to some newborns being brain-damaged and others dying, report findsEast Kent baby deaths: 45 infants could have been saved amid ‘downright dangerous’ culture
Up to 45 baby deaths could have been avoided at an NHS Trust whose treatment of pregnant mothers led to “significant harm”, a damning review has found.
Of the 65 baby deaths examined, there could have been a different outcome in 45 cases if care at the Trust had been complying with nationally recognised standards, a major review into maternity services found.
Women were subjected to a “downright dangerous” culture of assigning midwives who were not in the “favoured in-group” to high-risk cases and challenged to achieve a delivery with no intervention.
One woman who was concerned about her condition at an antenatal check was “dismissively” told to Google her symptoms.
A failure to learn from the shortcomings identified in the maternity departments of other scandal-hit trusts also contributed to the ongoing failures.
Hundreds of families have given evidence to the review, which was ordered by ministers last year. It is being led by Dr Bill Kirkup and examined 202 cases between 2009 and 2020 at the Queen Elizabeth The Queen Mother Hospital in Margate, and the William Harvey Hospital in Ashford.
The Telegraph previously revealed that more than 80 concerns about midwives and nurses working at East Kent Hospitals University trust have been investigated by regulators since 2015 – including cases involving the police.
Inspections last year found staff working 20-hour shifts in a desperate bid to cover shortages. They also warned of “horrific” morale among junior doctors, with some afraid to come to work because they felt out of their depth, and unable to get help from senior medics.
Report found staff ‘failed to listen to families’
The report states: “Those responsible for the services too often provided clinical care that was suboptimal and led to significant harm, failed to listen to the families involved, and acted in ways which made the experience of families unacceptably and distressingly poor.”
It said that between 2009 and 2020, “these problems could have been acknowledged and tackled effectively” and “the consequences of not grasping these opportunities are stark”.
Staff showed a “repeated lack of kindness and compassion” and a “victim mentality” prevailed.
“Those who should have provided leadership have been tempted to regard themselves as victims of geography, recruitment difficulties and a neglected estate,” the review states.
However, the review said the real failings were in teamwork, professionalism, compassion and listening.
It said shortgaes of staffing and resources did not play “a causative role in what happened”.
Panel heard ‘harrowing’ accounts from families
Dr Kirkup said his panel had heard “harrowing” accounts from families receiving “suboptimal” care, with mothers ignored by staff and shut out from their own care.
He told a press conference that there was a “substantial amount of anger” among families of those affected by failings in maternity care at the Trust.
“What has happened in East Kent is deplorable and harrowing,” said Dr Kirkup.
“In 45 of the 65 stillborn and newborn babies who died, there could have been a different outcome.”
“Unkind and callous” behaviour was shown towards mothers and families, and this has “deeply affected” them, he said.
There was a culture of treating patients “rudely, arrogantly and with hostility”. One mother, who lost her baby, was told that it was “God’s will”, the review found.
‘Extreme failures of teamworking’
Dr Kirkup also said there were “extreme failures of teamworking”. “A team that works to different goals, in my view, is not a team,” he said.
“An overriding 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,” the report said.
Overall, in nearly half of all cases examined by the panel, good care could have led to a different outcome for the families, the inquiry found.
Report found ‘tribalism’ and ‘bullying’ among staff
The report said “tribalism” among staff meant there were “gross failures of teamworking” at the Trust’s maternity services.
It reads: “Some staff have acted as if they were responsible for separate fiefdoms, cultivating a culture of tribalism.”
There was also a “lack of mutual trust, and disregard for other points of view”, the report said.
“We have found divisions among the midwives which at times included bullying to such an extent that the maternity services were not safe,” the report said.
Some obstetricians were also described by staff as having “challenging personalities” and “huge egos”, while midwives exhibited “cliquey behaviour”.
Staff were found to be disparaging about each other’s skills in front of patients, which caused distress.
One family member heard a consultant describe the unit they were in as “unsafe” to a colleague while speaking in a corridor.
Of 202 cases reviewed by the experts, the outcome could have been different in 97 cases, the inquiry found.
In 69 of these 97 cases, it is predicted the outcome should reasonably have been different and could have been different in a further 28 cases.
Of the 65 baby deaths examined, 45 could have had a different outcome if nationally recognised standards of care had been provided.
When looking at 33 of these 45 cases, the outcome would reasonably expected to have been different, while in a further 12 cases it might have been different.
Meanwhile, in 17 cases of brain damage, 12 (72 per cent of cases) could have had a different outcome if good care had been given, of which nine should reasonably have been expected to have had a different outcome.
NHS strain no excuse for ‘uncaring, rude or aggressive behaviour’
Dr Kirkup told the press conference that NHS staff being under strain was no excuse for “uncaring, rude or aggressive behaviour”.
He said: “We have to address problems of inappropriate and uncaring behaviour.
“NHS staff are operating under strain, but that is not an excuse for uncaring, rude or aggressive behaviour.”
He added: “What troubles me the most are the attitude and behaviour which dismissed women who had legitimate concerns and questions.”
Dr Kirkup said there was “no excuse for delay” in bringing changes to maternity services and we “must start now”.
Conclusions of investigation are ‘shocking and uncomfortable’
Dr Bill Kirkup said a culture of “deflection and denial” within NHS trusts when they are questioned about potential cases of substandard care is a “cruel practice” which “needs to be addressed”.
Speaking about the issue, he said: “This is a cruel practice that ends up with families being denied the truth.
“That’s a terrible way to treat somebody in the name of protecting your reputation.”
“I do recommend a statutory provision for this,” he added.
“It would place a legal duty on public bodies to be truthful and not to conceal problems.”
Dr Kirkup finished the press conference by saying: “The findings of the investigation are stark and the conclusions are shocking and uncomfortable.”
In response to the review, Health Minister Dr Caroline Johnson said: “I am deeply sorry to all the families that have suffered and continue to suffer from the tragedies detailed in Dr Bill Kirkup’s review.
“We are committed to preventing families from going through the same pain in future and are working closely with the NHS to continue improving the quality of care for mothers and babies with support teams for trusts, backed by £127 million to grow the workforce and improve neonatal care.
“We take these findings and recommendations extremely seriously and will review them all in detail ahead of publishing a full response.”