The hospital Trust board and our maternity clinicians are working closely with some of England’s leading maternity experts and with our health regulators to ensure that we have done - and we are continuing to do – everything we can to make rapid improvements to maternity care and to learn the lessons from past failures.
In January 2020 the inquest into the sad and tragic death of baby Harry Richford found that his death was wholly avoidable.
The death of any baby in a hospital maternity unit touches all of us. The loss of a life before it has barely begun is always deeply saddening. When it involves serious failings in the provision of care – as it did in the case of Harry Richford – it’s not just heart-breaking, it’s a tragedy.
It was clear that for some time we had not provided all the people of East Kent with the high level of maternity care they need and deserve. We apologise from the bottom of our hearts to Harry’s parents, to the rest of his family and to other families we have failed.
On 19 October 2022, the Independent Investigation published its report into our maternity and new-born services, Reading the signals.
The report describes the harm and suffering experienced by women, babies and their families, in our care between 2009 and 2020. We recognise that families came to us expecting that we would care for them safely, and we failed them. We unreservedly apologise for these unacceptable failings.
On 21 October 2022, the Trust Board met and formally accepted the report in full.
The report details systemic failures in care that led to significant harm, a failure to listen to families and staff, actions which made families experiences unacceptably and distressingly poor, and a series of missed opportunities to tackle the problems effectively.
It finds that had care been given to the nationally recognised standards, the outcome could have been different in 97 of the 202 cases assessed by the Panel (48% cases) and the outcome could have been different in 45 of the 65 baby deaths (69% cases).
The panel was unable to detect any discernible improvement in outcomes or suboptimal care, as evidenced by the cases assessed over the period from 2009 to 2020.
We fully accept the report’s findings and apologise unreservedly for the harm and suffering experienced by women and babies who were within our care, together with their families. We recognise that families came to us expecting that we would care for them safely, and we failed them.
We live and work among the people who use our services and we want to be their hospital of choice, providing safe services in a compassionate way.
Around 6,500 women give birth each year under the care of the East Kent Hospitals University NHS Foundation Trust (EKHUFT). We are determined to provide an excellent standard of care to every mother and child who uses our maternity service, and we will not rest until we, the public and our regulators are confident we are doing so.
History of maternity care.
In August 2014 the Trust was placed in special measures by the Care Quality Commission (CQC) following a full inspection of the Trust’s services. At the time of that inspection maternity services were rated as ‘Requires Improvement’ overall.
The CQC noted a lack of leadership, equipment shortages and a culture of bullying and harassment. During that CQC visit the maternity unit at Margate, though rated ‘Good’ for caring, was rated ‘Inadequate’ for safety.
Between that CQC visit and the subsequent CQC inspection, in July 2015, there were some improvements but the CQC still rated the Margate maternity unit as ‘Requires Improvement’ with similar themes to the earlier inspection.
In June 2015, the Medical Director and the acting Chief Nurse recommended to the Trust Board that an independent review of maternity services be commissioned from the standards department of the Royal College of Obstetricians and Gynaecologists (RCOG). The review was commissioned and took place at the end of November 2015.
The terms of reference for the RCOG review included a review of the provision of care in relation to national standards; a review of the workforce in relation to the level of clinical activity; a review of the education and supervision of obstetric middle grade doctors and trainees including consultant accessibility and presence on the delivery suite; and a review of the culture and relationships of the different health professionals involved in the delivery of maternity services. The RCOG review report was completed and sent to the Trust in February 2016.
The RCOG report noted that the number of stillbirths and deaths in the first 28 days after birth (neonatal deaths) in East Kent compared favourably with national statistics. However, the report also noted some service deficiencies and it made several recommendations for improvement. Specifically, the report noted a lack of consultant accessibility and presence on the maternity delivery suite. The actual number of hours per week of timetabled consultant presence (70 hours/week at Ashford and 60 hours/week at Margate) was consistent with RCOG guidance, but the impression the review team gained from talking to staff was that this level of presence was not consistently achieved.
Following receipt of the RCOG report the then Obstetrics and Gynaecology lead clinician and the Head of Midwifery at that time presented both the findings of the report and an improvement action plan to the Trust’s April 2016 Women’s Health Business and Governance meeting. Key recommendations were grouped into the following areas:
- Guidelines (ensuring consistency with national guidance, a clear process for development and review, medical engagement with both development and implementation, available to all staff as applicable)
- Incident reporting, investigation and learning
- Availability of consultants when on call and presence on the labour unit and escalation of instances of non-compliance with RCOG and local guidance governing the requirements for consultant presence
- Teaching and training of obstetric middle grades and trainees.
An audit was undertaken of consultant attendance at regular labour ward handover meetings for both weekdays and weekends. This showed good results on the Ashford site (98% attendance) but less good results in Margate (68% attendance) indicating a definite need for improvement. The job plans of the Margate consultants were revised to bring them in line with the Ashford consultants to deliver 70 hours per week of timetabled consultant presence.
The physical presence of consultants on the labour ward for the labour ward handovers and ward round meetings at Margate continues to be routinely monitored.
Further changes made in 2016 included:
- Adding more consultants, auditing senior clinician oversight of births at our hospitals and increasing the hours some consultants worked
- New standards for obstetric care on our labour wards were introduced
- Comprehensive training on identifying and safely supporting difficult births was instituted for all maternity staff
- Investment in maternity and neonatal equipment was increased.
In 2017, the Trust launched the Birthing Excellence: Success Through Teamwork (BESTT) maternity transformation programme, that includes ten specific safety actions aimed to:
- Halve the number of stillbirths and avoidable admissions into Neonatal Intensive Care by 2025
- Reduce the incidence of tears during assisted deliveries by 30%
- Develop digital solutions to improve access to and sharing of information. Examples include our maternity app and electronic antenatal records
- Transform education and learning for both midwives and medics, to ensure the service achieves all ten maternity safety actions
- Implement the ‘Saving Babies Lives’ care bundle and the recommendations from the national maternity review ‘Better Births’
A further CQC inspection in August 2018 acknowledged that the East Kent maternity service had made great strides to drive learning, improve outcomes and improve innovation through a collaborative and multidisciplinary approach but there were continued concerns in several areas indicating that more improvement work remains to be done.
In 2018, the Trust restructured its maternity service into a clinically-led service to provide more senior clinical support and oversight with a new Head of Midwifery and in 2019, a new clinical lead for obstetrics was appointed.
In 2019, the service also implemented a more comprehensive way of monitoring the fetal heart during labour (physiology–based cardiotocographic (CTG) interpretation) and the Trust appointed two new specialist, fetal wellbeing midwives to support and further train staff in monitoring babies’ wellbeing during labour.
In 2020, the Trust invested in centralised CTG monitoring, which allows continuous fetal monitoring to be displayed on monitors in the labour wards, midwifery stations and viewed by consultants elsewhere in the hospital or on call at home. This means staff can immediately be alerted to a potential problem and on call doctors will be able to provide expert opinion straight away, wherever they are.
The Coroner’s recommendations following the death of Harry Richford
In November 2017 Baby Harry Richford died in our care, following errors in his delivery and resuscitation at birth.
The analysis of the root cause of Harry Richford’s death noted failings similar to some of those in the RCOG review and CQC reports of 2014 and 2016. This suggested a failure to sufficiently embed learning. Since 2018 all Trusts across England have had the benefit of independent review of clinical incidents in maternity services from the Healthcare Safety Investigation Branch (HSIB). HSIB meets NHS Trusts every three months to review clinical incidents in maternity services. HSIB have now reviewed around 1300 cases nationally and the themes being identified across the country correspond to themes that have emerged in East Kent. These have been predominantly around cardiotocographic (CTG) monitoring, escalation to the consultant on call and communication both between different members of the maternity team and communication between sites.
Following the inquest into Harry’s death the Coroner noted a number of failings including:
- Hyperstimulation caused by an excessive use of syntocinon
- A failure to deliver within 30 minutes once Harry’s CTG reading had become pathological
- The delivery was a difficult one and should have been carried out by the consultant who should have attended considerably earlier than she did
- The locum on duty that night was relatively inexperienced and was not properly assessed
- There was a failure to secure an airway and achieve effective ventilation during resuscitation attempts after birth leading to a prolonged period of postnatal hypoxia.
- There was a failure to request consultant support earlier during resuscitation attempts
- There was a failure to keep proper account of the time elapsing during the resuscitation attempts with the effect that control was lost.
Specific issues raised during the Harry Richford inquest included questions on the presence of on-call consultants, locum recruitment and assessment, referral of neonatal deaths to the Coroner and CTG monitoring and interpretation.
In 2020, the Trust implemented all of the Coroner’s recommendations.
The Trust also committed to scrutinising robustly what had been done in response to the RCOG report since 2016, and also whether the Trust holds sufficient evidence of completion for each of the 23 recommendations.
It set up a Board Learning and Review Committee, chaired by an external senior clinician, to oversee this work. This was one element of the Committee’s remit to objectively and comprehensively examine the Trust’s governance of maternity services.
The findings from the review were published in July 2020. Of the 23 recommendations, the review considered that 13 had been met or partially met, but that for 10 of the recommendations, there was insufficient evidence of fully delivering the recommendation.
All the recommendations from the RCOG report, the CQC report and from elsewhere were incorporated into a single integrated action plan for maternity. The Trust Board’s Maternity Improvement Committee oversaw the plan so that progress could be robustly monitored and assurance provided. Its integrated action plan was reviewed and as of April 2021 agreed as met in full.
Between November 2020 and March 2021, the Trust’s Maternity Evidence Review Meeting Group provided detailed evidence aligned with each RCOG recommendation. Twenty two of the recommendations were agreed as fully met, one recommendation was partially met. This was detailed in the Trust’s public Board papers of 29 April 2021.
Our Strategy for Excellence in Maternity Care was published in January 2021.
Our strategy is one of continuous improvement, creating the right environment for our staff to be able to implement best practice and to have the confidence to raise concerns when standards are not being met. It’s our commitment to the women and families of east Kent to work tirelessly to provide high quality maternity care, which is safe, effective and centred on the women that need it.
Our strategy incorporates the recommendations from independent investigations, findings and feedback into maternity care at East Kent Hospitals to ensure the recommendations and lessons learned from these are fully embedded.
Ongoing oversight
The Maternity Improvement Committee concluded its work in August 2021. The Maternity and Neonatal Assurance group, chaired by the Chief Nursing and Midwifery Officer and attended by the NED maternity champion (a senior clinician), was established in September 2021, reporting monthly to the Quality and Safety Committee and directly to the Trust Board on a quarterly basis. It provides specific oversight of maternity and neonatal services, including training compliance, the monthly maternity dashboard which has 85 key performance indicators, maternity improvement plan, progress against CNST, Ockenden and CQC actions.
Its membership includes executive directors including the Chief Medical Officer, senior care group leaders, the Local Maternity and Neonatal System (LMNS) SRO, all maternity and neonatal safety champions*, the Regional Improvement Director and the Maternity Voices Partnership.
*Our Maternity and Neonatal Safety Champions include the CNMO, Interim Director of Midwifery, Non-Executive Director Maternity Champion and two lead consultants in women’s health and neonatology.
