Maternity scandal trust calls in senior clinician to lead review

Des Holden, medical director of the Kent, Surrey and Sussex Academic Health Sciences Network and a respected obstetrics and gynaecology consultant, will chair a sub-committee set up for the purpose by East Kent Hospitals University Foundation Trust.

The trust said the sub-committee would be ”reviewing the actions the trust took since the Royal College of Obstetrics and Gynaecology report on our service undertaken in 2015; reviewing our “BESTT” maternity improvement programme; ensuring we are complying with national safety standards and are implementing the coroner’s recommendations following the inquest of baby Harry Richford, fully and swiftly.”

It comes as the coroner in the inquest into the death of Harry Richford — which has prompted the revelation of a series of other serious concerns about maternity services at East Kent — today publishes recommendations for the system in a “prevention of future deaths report”.

A new trust board paper says the new sub-committee or “panel” will look across midwifery, paediatrics and obstetrics, and will also “establish a process to implement, embed and assure the coroner’s recommendations”. It will review “obstetric and paediatric medical job plans”, serious incidents and the response to them, carry out a “data review”, and look at the paediatric emergency department.

The three week inquest into Harry Richford’s death, at the Queen Elizabeth the Queen Mother Hospital in Margate in 2017, heard of numerous failings in his care and a chaotic environment, when he was born after a difficult emergency Caesarean section, and had to be resuscitated.

Pressure on the trust has increased in recent days with Canterbury MP Rosie Duffield calling for an inquiry and new cases where babies died being reported by the BBC.

Reports from the Care Quality Commission and Healthcare Safety Investigations Branch on maternity services at the trust were also due to be delivered to ministers by today.

In the prevention of future death report, coroner Christopher Sutton-Mattocks calls for NHS England and the RCOG to consider a national review of the recruitment, supervision and assessment of locums on maternity wards and potential new guidance. The coroner warned there may be “a risk to lives at this trust and at other trusts in the future” as this was a national problem.

It calls on the trust to consider:

• Ensuring a dedicated medical consultant reviews references and CVs of locums before they are employed, and consultants who work with them should give feedback;
• Drills and simulation as part of the training for neonatal resuscitation; and
• The circumstances where anaesthetists play a role in neonatal resuscitation. The anaesthetist looking after Harry’s mum, Sarah, had to leave her to assist in resuscitating Harry. He told the inquest he had done this working in Nepal but it was unusual to do it in the UK.

Meanwhile, the trust has within the last month put on its risk register a risk of providing sub-optimal care in maternity.

An “extreme” risk against not delivering the actions in the RCOG report was previously put on the risk register in June 2016, with a delivery date of October that year. By February 2017 this had changed, with a new delivery date of March 2018. But the remaining actions were later given a date of March 2020 — which the trust says was because they were cultural changes.

HSJ understands the trust’s council of governors discussed maternity in an extraordinary meeting last week, at which assurances were sought that there were no further failings still to be revealed. No papers for this meeting were put on the trust’s website, with the organisation claiming it was not a meeting held in public, so they would not be published.

Updated 11 February at 11.30am when we were supplied with the name of the clinician leading the work.