Independent inquiry called into East Kent maternity scandal

1 Comment

Comes after at least six avoidable baby deaths reported at trust since 2011
Investigation reports from CQC and HSIB to be published “in due course”
Trust also announces fresh review of all perinatal deaths in the last decade

NHS England and Improvement will commission an independent inquiry into maternity services at East Kent Hospitals University Foundation Trust, junior health minister Nadine Dorries has announced.

The independent review, which will look at preventable and avoidable deaths of newborns in partnership with affected families, will be led by Dr Bill Kirkup - who chaired the inquiry into Morecambe Bay’s maternity services.

The review will also consider what wider regulatory or practice changes are needed to guarantee safe services at any other maternity units.

A total of 26 maternity cases, dating back to 2011, are currently being investigated by the Healthcare Safety Investigation Branch, while it has been reported there have been at least six avoidable baby deaths in that time period.

In a statement to the House of Commons today, Ms Dorries also said reports of investigations into the trust’s maternity services by the Care Quality Comission — which recently carried out an unannounced inspection — and HSIB will be published “in due course”.

She said: “These identified a number of safety concerns, including the availability of skilled staff — particularly out of hours — access to neo-natal resuscitation equipment, the speed at which patients’ concerns are escalated to senior clinicians and obstetricians, along with failings in leadership and governance.

“From the findings provided to me by HSIB and CQC, it is clear that the challenges at East Kent point to a range of issues including having the right staff with the right skills in the right place, effective multidisciplinary working, clear collaborative working between midwives and doctors, good communication and leadership support.

“But it would be wrong to speculate that there is one single cause.”

Ms Dorries added HSIB’s investigation at the trust was part of its national maternity investigation programme, which has reviewed hundreds of incidents.

HSIB has also been asked to carry out a “deep dive” at the trust to look at both historic and more current maternity cases, she said.

Ms Dorries said NHSE’s chief midwifery officer Jacqueline Dunkley-Bent has sent an “expert” independent clinical support team into East Kent, including a midwifery director of an outstanding-rated trust, to oversee the care being delivered.

The trust also announced today it would review all perinatal deaths in the last decade. The probe - which is likely to involve hundreds of cases - was announced at its board meeting today.

Are any of you going to resign?

A sombre board today faced challenges from members of the council of governors as chief executive Susan Acott and medical director Paul Stevens outlined the trust’s response to concerns about maternity care, highlighted by the inquest into Harry Richford last month, writes Alison Moore.

Harry died a week after his birth at the Queen Elizabeth, the Queen Mother, Hospital in Thanet - a death the coroner ruled was “wholly avoidable” and which has led to other families who lost babies coming forward, alleging failures in care.

Ms Acott announced the review of perinatal deaths would lead to a report which would be made public, and said it would identify any cases which needed to be referred to the coroner. The trust is also planning to recruit six new obstetric consultants and six new middle grade doctors to bolster its services.

Ms Acott – who had to stop speaking momentarily at several points – apologised to Harry’s family and other families who she said “the trust has not served well…..It is clear for some time that we have not provided the people of East Kent with the level of maternity services they deserve”.

The trust had not listened enough, she said, pledging to meet with each of the families whose cases had come to light. “There has been a culture of denial. We need to replace it with a lot more receptive and open culture,” she said.

And, while she said the trust had been changing, this needed to happen faster. Dr Stevens, who is standing down as medical director but is continuing as a consultant, admitted there had not been “sustainable, embedded learning”.

Ms Acott added that feedback from the Care Quality Commission, which made an unannounced visit to maternity services recently, had led to immediate plans for changes around maternity triage and the maternity day unit.

But the board faced scrutiny from a large number of governors who attended. Public governor Alex Lister said: “There are two scandals — one is the failure of medical care and the other then inability of the trust to communicate.”

Changes at the top were needed in order to restore trust, he said, asking whether Ms Acott, Dr Stevens, trust chair Stephen Smith and director of communications Natalie Yost intended to resign. They declined the invitation.

Ms Acott stressed the importance of continuity of leadership. She said: “We need to use the memory of Harry Richford to maintain our energy and focus around the changes we are trying to make.”

Updated at 2.15pm to include reporting from East Kent board meeting, and at 4:46pm to include further details of the inquiry.