MATE RNI T Y
Inquiry into East Kent Hospitals NHS Trust
More recently (in March 2021), an inquiry into poor maternity care at East Kent Hospitals NHS Trust was also launched, after it was revealed that more than 130 infants had suffered brain injuries during birth at the Trust over several years. Issues with maternity services at the
Trust were first brought into the spotlight following the death of baby Harry Richford at Margate’s QEQM Hospital in 2017 after a series of errors. An inquest ruled that Harry’s death was “contributed to by neglect”3
and, on the 18 June 2021, the CQC announced that it had successfully brought a prosecution against the Trust. East Kent Hospitals NHS Trust was ordered to pay a total of £761,170, after admitting it had failed to provide safe care and treatment resulting in avoidable harm to both Harry Richford and his mother, Sarah Richford. The final report into maternity care at
the Trust will be led by Dr. Bill Kirkup (who had a prominent role in the Morecombe Bay inquiry) and the full investigation findings will be published in autumn 2022.4 However, the Healthcare Safety Investigation Branch (HSIB) has already provided some insights into failures at the Trust’s maternity care5
and a report
published last year identified some key themes around risks to patient safety. These included:
Interpretation of CTG monitoring: The investigations identified concerns related to the unavailability of staff with suitable skills in reading and interpreting CTG results. They also indicated there were issues, specifically around consistency with categorisation tools and guidance, which were available to staff to enable them to recognise results that are of concern or require escalation. Neonatal resuscitation: Effective and timely neonatal resuscitation was an area of concern across many of the investigation reports. Specifically, the reports highlighted the physical environment as a barrier to effective and timely resuscitation. The location of resuscitation equipment added
delay, risk and distress to critical situations and staff responsible for resuscitation were often under supported by appropriately skilled colleagues. Recognition of deterioration:
Deterioration in the condition of mothers and babies occurred in several cases because staff had not recognised the signs and symptoms that indicate deterioration. As a consequence, clinical interventions that could have prevented further deterioration were missed.
Escalation of concerns: Processes and procedures for escalation were not consistently applied. This appeared to be due to multiple factors that undermined their practical application in the working environment. These factors included site- based team alliances, professional team alliances, skill gaps across specialisms and across community and hospital- based teams. Staff interviewed repeatedly conveyed a reluctance of midwifery staff to escalate concerns to obstetric and neonatal colleagues.
Health and Social Care Committee Inquiry
Against this backdrop of high-profile failures,
The Committee’s first evidence session, heard from Michelle Hemmington, whose son, Baby Louie, tragically died following mistakes in her care during labour. She recalled that the first thing said to her, when she arrived at the hospital in labour, was that she had “picked a bad day to have a baby as the unit was really busy”.
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the Health and Social Care Committee launched its own inquiry into maternity safety and commissioned an independent panel of experts to assess the Government’s progress in meeting its own targets in key areas of healthcare policy, relating to maternity services.6,7 Key findings included a lack of safe staffing levels on some maternity units and challenges around funding. Professor Ted Baker, chief inspector of hospitals at the Care Quality Commission (CQC) told the inquiry that more than a third of CQC ratings for maternity services identified requirements to improve safety, larger than in any other specialty.
The Committee’s first evidence session, heard from Michelle Hemmington, whose son, Baby Louie, tragically died following mistakes in her care during labour. She recalled that the first thing said to her, when she arrived at the hospital in labour, was that she had “picked a bad day to have a baby as the unit was really busy”. Although factors other than staffing contributed to Michelle and Louie’s tragedy, Michelle highlighted staffing as a key issue. She said that there needed to be “more staff involved” and that there needed to be “more staff on labour wards and in maternity”.
Suboptimal staffing levels were also identified in the Morecambe Bay report, and Professor Ted Baker told the Committee that after Morecambe Bay the CQC was “very assertive in insisting that units have the right level of staffing”.
He went on to state that a number of factors affected the level of staffing including “a big attrition rate” in trainee obstetrics and midwifery; incidences of bullying; and problems with the workplace culture. “There is an issue of staff numbers, but there is also an issue of how we look after the staff we have,” he commented, adding: “The number of midwives has been a
SEPTEMBER 2021
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