This investigation was triggered by the sadly avoidable death of Harry Richford in 2017, after which his parents and grandparents started their tireless campaign for answers.
The investigation, fully reported here, involved a review of 202 cases. These cases were selected from a group of families who were willing to participate. Dr Kirkup’s independent report included family listening sessions, a consideration of the clinical records and interviews with clinical staff. The cases spanned the period from 2009 to 2020.
He concluded that, had care been given to nationally recognised standards, the outcome could have been different in 48% of the cases reviewed. Forty five out of sixty five cases of baby deaths could have been avoided (69.2%) and twelve out of seventeen cases of brain injury (70.6%) could also have had a different outcome.
There were also cases where there were “near misses” and it was only by chance that the substandard care provided had not resulted in a grave outcome for the women and babies involved.
Failure to listen and lack of compassion
The report highlights that there was a failure to listen to parents and the investigation repeatedly heard that women lost confidence in their care due to poor communication and an unwillingness, by clinicians, to involve women in the decisions about their care.
Particular issues included:
- Not being listened to or consulted (particularly where first-time mothers were involved and particularly in relation to reduced fetal movements).
- A reluctance of staff to discuss birth plans; pressure about the mode of delivery, with caesarean section being described as a “swear word” on one ward; and a total lack of kindness and compassion.
- Women who had lost their babies were being placed in wards with mothers and their new-borns and they and their partners were being left for long periods of time without being told that their babies had passed away.
Failure to consent
Doctors and midwives were found to have failed to ensure that risks were properly explained to women, when seeking consent, and women felt that they were particularly “browbeaten” into giving consent in emergency situations.
This was another area of serious concern. Clinicians were failing to hand over effectively at shift change and there was a failure to communicate effectively between the various services involved in maternity and neonatal care.
Laying blame and the duty of candour
A startling feature of the report is the collective failure of the trust and its employees to be open and honest and to comply with the duty of candour (brought in in 2014). The trust was not taking responsibility for its errors and was, in fact, seeking to blame the women for what had happened to their babies. There were also consultants who would “take no responsibility for their actions and blame colleagues for any challenges and failings”.
Denise Stephens, a partner in Shoosmiths’ Thames Valley office (Reading), who acts for a child who suffered a severe hypoxic brain injury arising from sub-standard maternity care at the East Kent Hospitals University NHS Foundation Trust, commented:
“The findings in this report are devastating for the parents involved. They will have done everything that they could to keep their babies safe and have been badly let down by the trust. Unfortunately, this is something that we see happening to families all over the country and is not confined to East Kent.
“This investigation is, sadly, not the only one to conclude that maternity and neonatal care in England is sub-standard. The reports into the Shrewsbury Trust earlier this year, and the Morecambe Bay investigation in 2015, highlight that improvements must be made.”
Denise added: “The parents and families who have been through these awful events and who now live with guilt, loss and despair should be applauded for their passionate determination to ensure that changes are made, so that future adverse outcomes can be avoided.
“We hope that our actions in highlighting the issues that our clients bring to us, help the NHS to address these failings and that the NHS embrace and act upon the recommendations in Dr Kirkup’s report.”
This information is for educational purposes only and does not constitute legal advice. It is recommended that specific professional advice is sought before acting on any of the information given. © Shoosmiths LLP 2023