East Kent hospitals: Criminal investigation into baby deaths at maternity unit

Warning in 2016 that lives were at risk because consultants were not showing up for weekend and evening shifts

Shaun Lintern
Health Correspondent
Thursday 23 January 2020 10:59 GMT
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An inquest into the death of Harry Richford who died in November 2017 is due to conclude on Friday
An inquest into the death of Harry Richford who died in November 2017 is due to conclude on Friday

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The hospital at the centre of a series of baby deaths is under criminal investigation after an unearthed report identified many of the safety issues in the maternity unit as early as 2015.

The Independent has learned of dozens of deaths at east Kent hospitals with more than 130 babies suffering brain damage as a result of being starved of oxygen during their birth over a four-year period.

Doctors at the Queen Elizabeth The Queen Mother in Margate are also being investigated by the General Medical Council following seven-day-old Harry Richford’s death as a result of catastrophic errors during his birth.

An inquest into Harry’s death in 2017 is due to conclude on Friday, and doctors have told the coroner of panic in the operating theatre during his caesarean, while the inexperienced locums in charge admitted being “out of his depth”.

Harry suffered a severe lack of oxygen and brain damage after a delay of more than 25 minutes in helping him breathe. East Kent Hospitals University Foundation Trust, which encompasses five hospitals and community clinics, has apologised for failures in his care and today accepted it had failed other women and their babies.

An expert review of the maternity services by the Royal College of Obstetricians and Gynaecologists (RCOG) carried out in 2015 had warned of many of the issues that played a part in Harry’s death, including the reluctance of a group of senior doctors to attend during evening and weekend shifts leaving ill-prepared junior doctors and midwives to care for complicated births.

The experts explicitly warned bosses at the trust that if action was not taken it would mean consultants not committed to teaching and supervision would “be on-call with a locum middle-grade doctor, potentially of unknown competence, which could impact on the safety of care in the maternity unit”.

An audit by the trust in 2016 revealed only a 68 per cent attendance rate for consultants at the Margate hospital.

Now it has emerged that safety concerns at the trust date back at least to 2014. The NHS trust was rated inadequate in that year and put into special measures by the Care Quality Commission. It left special measures at the start of 2017.

The Independent has seen evidence of a number of repeated errors at the trust including baby deaths and children left brain-damaged by delays in treatment and not recognising the deteriorating heart rates of babies in distress.

Between 2014 and 2018 there were 68 baby deaths at the trust for children aged under 28 days old and of those, 54 died within their first 7 days. There were 143 stillbirths, although this includes some late terminations.

In total 138 babies suffered brain damage after being starved of oxygen during birth.

The trust told The Independent it had recorded 81 separate serious incidents in maternity care during the four-year period.

The CQC is investigating the case and may bring a prosecution under regulation 12 of its ‘fundamental standards’ which requires a care provider to deliver safe care. Where a patient suffers avoidable harm the provider can face an unlimited fine once convicted.

Professor Ted Baker, chief Inspector of hospitals at the Care Quality Commission said the watchdog had a legal duty “to investigate and, where appropriate, to prosecute a provider registered with us for a failure to provide safe care or treatment resulting in avoidable harm or a significant risk of avoidable harm”.

“We are unable to comment on an ongoing criminal investigation”, he added.

The trust is to receive specialist support from NHS England’s national maternity safety programme to help improve care.

A spokesperson for East Kent Hospitals said: “We recognise that we have not always provided the right standard of care for every woman and baby in our hospitals and we wholeheartedly apologise to families for whom we could have done things differently.

“We are reviewing our service with some of England’s leading maternity experts to make sure we are doing everything we can to make rapid improvements to maternity care in east Kent.

“We recognise, however, that the scale of change needed in our maternity service has not taken place quickly enough and we need to fully embed further learning and changes to our culture.

“We will also recruit more doctors to further improve 24/7 care on our labour wards.”

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