East Kent NHS inquiry finds better care might have prevented 45 babies’ deaths

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The deaths of at least 45 babies could have been avoided if nationally recognised standards of care had been provided at one of England’s largest NHS trusts, a damning inquiry has found.

Dr Bill Kirkup, the chair of the independent inquiry into maternity at East Kent hospitals university NHS foundation trust, said his panel had heard “harrowing” accounts from families of receiving “suboptimal” care, with mothers ignored by staff and shut out from discussions about their own care.

The inquiry’s report said: “An overriding theme, raised with us 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.”

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 it could have been different in a further 28 cases.

Of the 65 babies’ 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% 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.

In nearly half of all cases examined by the panel, good care could have led to a different outcome for the families.

Some of the bereaved parents accused the trust of “victim blaming” mothers for their children’s deaths.

Kelli Rudolph and Dunstan Lowe, whose daughter Celandine died at five days old, said: “Doctors sought to blame Kelli for Celandine’s death. This victim blaming was the first in a long line of interactions with those in the trust who sought to delay, deflect and deny our search for the truth about what happened to our baby.

“In isolation, these tactics traumatised us after the tragedy of our daughter’s death. But when seen in the light of 10 years of failures, they signal a concerted effort to cover up the trust’s responsibility for what happened to Celandine and the many others who lost their lives due to failures in clinical judgment.”

Helen Gittos and Andy Hudson, whose full-term, healthy daughter, Harriet, died in 2014, said: “Too often during pregnancy, in labour and afterwards rather than being listened to, we were treated dismissively, contemptuously and without a desire for understanding. These are not the conditions in which good care can happen or good learning take place.

“It is hard enough to come to terms with the death of a child; it is even harder when you are implicitly blamed for what happened.” NHS staff and students in medical schools needed to discuss “why mothers in particular are so often blamed when things go wrong in the care of their children”.

Gittos set up a support group for families who had received poor maternity care at East Kent.

Tracey Fletcher, the trust’s chief executive, emailed its staff last week warning them to expect that Kirkup’s findings would be a “harrowing report which will have a profound and significant impact on families and colleagues, particularly those working in maternity services”.

The scandal was first exposed in January 2020 by the BBC. Evidence soon emerged that the trust’s failings in maternity care stretched back years and involved a large number of families. In February, Nadine Dorries, at the time a health minister, asked Kirkup to investigate.

This is the fourth inquiry that Kirkup, an obstetrician, has undertaken. He has previously produced major reports on the maternity scandal in Morecambe Bay, the disgraced entertainer Jimmy Savile’s involvement with Broadmoor secure mental health hospital and problems with the children’s heart surgery unit in Oxford.