East Kent Hospitals Baby Death InvestigationPublished on: 12 February 2020
At Lanyon Bowdler we have been working on behalf of a significant number of families affected by failures at the Shrewsbury and Telford Hospital NHS Trust, which has hit headlines again recently after news broke about the leaked independent inquiry report. It is therefore all the more concerning to read the recent news coverage concerning East Kent Hospitals NHS Trust which sadly tells an all too familiar story.
Investigation into East Kent Hospitals NHS Trust
Last week, a BBC investigation discovered that since 2016, at least seven preventable baby deaths may have occurred at East Kent Hospitals NHS Trust. One of those is Harry Richford who was born at the Queen Elizabeth The Queen Mother Hospital in Margate in November 2017. Harry sadly passed away just a week after he was born following complications with his delivery and neonatal care.
On Friday 24 January 2020, coroner Christopher Sutton-Mattocks ruled that Harry’s death was “contributed to by neglect” and “wholly avoidable”. The BBC reported that the coroner identified a number of failings in Harry’s care including, but not limited to, failure to expedite delivery once the cardiotocography (CTG), which monitors a baby’s heartrate, had become pathological and a lack of consultant involvement during both the delivery and resuscitation attempts.
Upon conclusion of the inquest, Harry’s father, Tom Richford said, "Accidents happen every day but failing to learn from them appears to have become part of the culture of this trust. It was known there was a risk. The risk was present as far back as 2014." It is that failure to learn from mistakes which is most familiar to those of us working with clients who have been failed by maternity services. We have heard from many clients who were told by the hospital treating them that lessons have been learnt from their case, and yet more cases with similar facts continue to come to light.
A 2015 report by the Royal College of Obstetrics and Gynaecologists (RCOG) reviewing obstetric services at East Kent Hospitals NHS Trust uncovered a number of concerning findings that contributed to Harry’s death, including a reluctance/refusal by some consultants to attend out of hours when requested and a failure to attend CTG training. Despite these concerns however, the full report was not provided to the Care Quality Commission (CQC) until January 2019.
Criticisms from Dr Bill Kirkup CBE
This was heavily criticised by Dr Bill Kirkup CBE, the Chairman of the Morecambe Bay investigation into maternity and neonatal services at Furness General Hospital. He told The Independent: “When there is sufficient concern about a service to prompt an external review, the report must be available immediately to those responsible for assuring the quality of the service. That was the reason for the recommendation of the Morecambe Bay investigation, and it is disappointing that the Care Quality Commission apparently had no sight of this report until now.”
Towards the end of 2019 my colleague, Beth Heath took part in BBC Radio 4’s Women’s Hour alongside Dr Kirkup, discussing the news coverage regarding Shrewsbury and Telford Hospital NHS Trust. He made it clear that he hoped that lessons would be learnt from the Morecambe Bay investigation report, which was circulated to other hospital trusts in 2015. Sadly there continues to be a worrying pattern of repeated failings in maternity care despite the rhetoric from hospital trusts of “lessons being learnt”.
Following the conclusion of Harry Richford’s inquest, East Kent Hospitals NHS Trust is now under criminal investigation by the CQC.
Lanyon Bowdler’s award winning clinical negligence team includes members of the Law Society’s Clinical Negligence Panel and AvMA panel members. The team has extensive experience of dealing with birth injury cases, in particular cases involving neonatal deaths and we are handling many cases arising out of the Shrewsbury and Telford Hospital NHS Trust baby death scandal. If you have concerns about the maternity care you have received, our team are happy to discuss the matter with you and guide you through the process sensitively.