More failings discovered at maternity scandal trust

East Kent Hospitals University Foundation Trust revealed the developments in a new board paper.

It said the Care Quality Commission highlighted:

• Issues with processes for fetal monitoring and escalation at the William Harvey Hospital, Ashford. There had been “incidents highlighting fetal heart monitoring” problems in September and October, and the trust’s measures to improve processes were not “embedded and understood by the clinical team”;
• Slow maternity triage, due to staffing problems, and infection control problems at the William Harvey. The trust is reviewing how issues with infection prevention and control and cleanliness were not identified or escalated; and 
• Fire safety issues at the Queen Elizabeth, the Queen Mother Hospital, in Thanet with problems linked to fire doors and an easily accessible secondary fire escape route.

Three years ago issues with reading and acting on fetal monitoring were highlighted at the inquest into baby Harry Richford, whose poor care by the trust led to an independent inquiry into widespread failings in its maternity services, led by Bill Kirkup.

The trust’s board papers for this week said there is evidence of improvement in the CQC’s “well led” judgement, but “there is still work to complete especially for the effective and safe domains”.

The CQC’s report has yet to be published but the trust’s initial response to feedback was given in the board paper.

The board papers also revealed the trust has not met the standards for a discount under NHS Resolution’s clinical negligence scheme for trusts, which will cost it between £700,000 and £900,000 in higher premiums. It was not compliant with requirements on using the perinatal mortality review tool, and on multi-professional training in anaesthetics. Chair Niall Dickson has said it should aim to comply next year.

The CQC criticisms come as the trust publishes its interim response to the independent Kirkup inquiry, which highlighted failures in teamworking and professionalism; a lack of compassion and failure to listen to women; and denial and deflection, including at board level. The review concluded that 45 out of 65 baby deaths it examined could have been avoided if care had met national standards.

The trust is now planning to publish an open letter in local media, apologising for what has happened and pledging it will use the lessons in the review into maternity services, which reported last October, to “put things right”. It promises a “fundamental transformation of the way we work” and says key performance indicators will measure progress over the next three years, with short, medium and three-year goals.

The open letter will come from Mr Dickson and the chief executive, Tracey Fletcher. The board will be asked to review the wording this week; but it will summarise the report, before going on to “apologise” to the community, including for the anxiety its failings will have caused.

“We are aware that saying sorry is not enough and that what is needed is meaningful action and real change. We are also clear that there is learning from the lessons in the report for every area of our organisation; these are not just confined to maternity,” the draft says.

It acknowledges previous attempts to tackle some of these problems have not been successful, adding: “We are determined to make sure that does not happen again.” 

The trust has also set up an independent case review process to respond to families who have concerns about the maternity or neonatal care they have received, with 11 reviews due to start this month. This is in addition to 202 cases Dr Kirkup looked at, although new concerns from those families could also be examined.

Disappointed

Minutes for a December meeting, also newly published, revealed non-executive directors were concerned to find staff in the maternity units had not read Dr Kirkup’s review.

Last week, Dr Kirkup told the North East and North Cumbria Integrated Care Board he was “disappointed” with the response to the inquiry, which was published at a time of political turmoil. “There is a real danger that people will find a way to take eyes off the ball because it is all history now,” he said.

He added he had had “constructive” discussions with NHS England which wanted to produce a combined response to the Shrewsbury and Telford maternity report and East Kent’s but it had taken until last week to get a meeting with health minister Maria Caulfield.

And he warned, given the anger of the families: “There are going to be problems if there is nothing forthcoming from the government.”

East Kent has been approached for comment.