28 October, 2022
On 13 February 2020 Nadine Dorries MP, the Minister of State for the Department of Health and Social Care, confirmed in Parliament that NHS England and NHS Improvement had commissioned an investigation into maternity and neonatal services at East Kent Hospitals University NHS Foundation Trust. Dr Bill Kirkup CBE was tasked with heading up the investigation. The investigation was announced following concerns about the death of a number of babies in hospitals in the East Kent Region.
The investigation focused on maternity services in The Queen Elizabeth Hospital at Margate and the William Harvey Hospital in Ashford between 2009 and 2020. The investigation found that "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."
The investigation uncovered problems at every level within the maternity and neonatal services at these hospitals. Whilst there were shortcomings in terms of hospital infrastructure and the Trust had experienced resource shortages at times, these factors did not cause the poor practice that resulted in preventable deaths.
The findings of the report are shocking. Midwives who were not part of the favoured 'in-group' at the William Harvey Hospital were sometimes given the highest-risk births and challenged to deliver the baby with no intervention. This was "downright dangerous practice". One mother reported that her spinal or epidural pain relief was not effective and that she was in pain during childbirth; pain that was not dealt with by staff. Another mother told the investigation that "they didn't listen… they carried on, obviously, to cut me open. I could feel it all."
The Trust displayed numerous serious failings in terms of teamwork, communication with patients and families, professionalism, failures in compassion and listening to parents and failures in acting on high-risk situations. The Trust generally was found to have provided inadequate responses when concerns were raised, in which the Trust seemed to minimise problems with the care provided. This gave the appearance of the Trust 'covering-up' how bad the situation actually was. The Trust did not understand why parents and families would complain if both the mother and baby had survived.
These failings led to avoidable injuries to both babies and mothers, and sometimes tragically resulted in death. The following case studies go into more detail about how the Trust's poor practice resulted in harm to a mother, and then in the sad death of a baby.
Mother B was pregnant for the first time. At 39 weeks pregnant, B developed two significant complications of pregnancy: pre-eclampsia and obstetric cholestasis, a liver condition. Despite the risk, B was only monitored intermittently. B's baby was born via caesarean section uneventfully, although there was a need for extra stitching to control blood loss from the incision. After the birth, B and her family were sent to a recovery room. Her family were shocked to see blood emerging from under B's blanket, and realised that B was bleeding very heavily. They raised the alarm, and the staff implemented the hospital's protocol for massive postpartum haemorrhage.
B was taken to theatre and operated on for a suspected atonic uterus - this is when the uterus has not contracted effectively after birth. A Bakri balloon was placed in the uterus and inflated to reduce the bleeding. Meanwhile, the family remained with the baby.
The family recall B's consultant saying "you're really lucky because I've phoned a friend" and "oh no, we're going 50/50 next and then we're going to ask the audience." They were dismayed that the consultant obstetrician was using such flippant language to describe B's potentially life-threatening condition. The 'friend' was a consultant gynaecological oncologist who carried out an exploratory operation. They found an extensive collection of blood alongside the uterus, from a tear in the cervix possibly caused during the caesarean or insertion of the Bakri balloon. The consultant tied off the blood vessels and evacuated the blood, but B required extensive blood transfusion.
B was told that she shouldn't leave the hospital as she was "like a broken car that we've fixed up and if you leave you might just break down again." B was distressed by this and found it very insensitive.
After B's family sent a letter of complaint, they were informed that the neonatal unit was safe with mortality rates below the national average. When they asked to see the review put together by the hospital, they were told that, that was not how reviews work. The family were told that the haemorrhage could not have been avoided. The hospital could not understand why B was complaining when both her and her baby had survived. The hospital failed to consider the physical and mental pain that B had been through, leaving B terrified about becoming pregnant again. It appeared that at no point had B been told that the bleeding was due to surgical injury to her cervix and vagina.
Mother C, a young mother, arrived at hospital having had a healthy pregnancy up until this point. She had noticed that the movements of her baby had been slowing down, but a community midwife had assured her that this was not a cause for concern. C went into labour late in the evening, and was told to wait until her contractions were stronger and more frequent before travelling to the hospital. She was discouraged by this and waited until the following afternoon before going into hospital. Her baby's movement were still slow.
When C got to hospital, she vomited in the corridor. This is often a sign of a rapidly progressing labour. A midwife attempted to detect the baby's heartbeat using a 'doppler', the standard method for doing so. However, they accidentally picked up C's heartbeat instead. The midwife then went on a break and was replaced by another, who noticed that the baby's heartbeat was not recovering quickly enough after the contractions. C was taken to the labour ward.
C's baby was delivered with forceps and placed straight into a resuscitation cot, before being taken to the neonatal intensive care unit. C was bleeding profusely and her dad left the room to get a member of staff, only to be told that "they are all in the staffroom having a cup of tea to recover from the shock." When the consultant obstetrician arrived, C was given the awful news that her baby might not survive, or might survive but with brain damage. In the coming days, C and her partner tragically saw the effects of their baby's organs shutting down. The baby sadly passed away in C's arms the following day.
A number of months later C's family had a meeting with the Head of Midwifery and head of the Midwife-Led Unit at the hospital. They were told that "many, many mistakes had been made" and that their baby's death could have been prevented had delivery happened a few hours earlier. C was told that ten babies had died since her own. The investigation report notes that many incidents similar to C's happened at the Trust.
The report found that 45 babies could have survived if they had received better care at East Kent NHS Hospitals Trust.
Unfortunately, injuries to both babies and mothers during childbirth can happen, and sometimes they can happen even if the medical team do everything correctly. However, this report highlights the types of injuries that can happen as a result of medical negligence, whether it be a failure to deliver a baby quickly enough causing harm to the baby, or surgical mistakes resulting in injury to the mother.
The problems highlighted here are sadly not limited to the East Kent Trust.
If you feel that you or your baby may have suffered similar avoidable harm, Forbes can help. We understand that, in the event of a mother or baby being injured during childbirth, litigation is the last thing on your mind. Our dedicated team of clinical negligence solicitors and litigation lawyers will be able to initiate and progress your claim on your behalf, to ensure that your stress is kept to a minimum. Our team will allow you to focus on rebuilding your health and supporting your family during the most difficult of times.
For more information contact Leonie Millard in our Clinical Negligence department via email or phone on 01254 770517. Alternatively send any question through to Forbes Solicitors via our online Contact Form.
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