A damning report into the care provided to women and babies at an NHS trust in Kent will be published on Wednesday.
The study, which marks the culmination of an independent inquiry into maternity at East Kent Hospitals University NHS Foundation Trust, is expected to describe how newborn babies died due to poor care spanning several years.
It is thought the report will tell how grieving families were often ignored or had their concerns overlooked, while valuable lessons were not learned by the trust.
East Kent Hospitals University NHS Foundation Trust has been subject to the independent review carried out by Dr Bill Kirkup. Services at three hospitals have been investigated - the William Harvey at Ashford, the Queen Elizabeth the Queen Mother in Margate and the Kent and Canterbury Hospital.
Since the investigation was launched, more than 200 families have come forward to have their own maternity cases examined.
The inquiry which is investigating preventable and avoidable deaths of newborns is expected to expose a catalogue of serious failings within maternity and neonatal services at the trust over the last decade.
The investigation was triggered following the death of newborn Harry Richford.
Harry died seven days after his emergency delivery at the Queen Elizabeth Queen Mother Hospital in Margate in November 2017.
One midwife described “panic” during attempts to resuscitate Harry, while a staff nurse said the scene was “chaotic”. Following Harry’s death, the East Kent Trust recorded his death as “expected” and did not inform the coroner.
In January 2020, the inquest into his death revealed that he had died due to seven gross failings which, the coroner said, amounted to neglect.
The total fine of £1.1million was reduced to £733,000 owing to the trust's guilty plea.
The case was the the trigger point for the public inquiry into maternity services at three hospitals run by the East Kent University NHS Foundation Trust.
A panel of medical experts, led by Dr Bill Kirkup were tasked with looking at maternity and neonatal services at the William Harvey Hospital in Ashford, the Queen Elizabeth Queen Mother in Margate and the Kent and Canterbury Hospital.
Speaking when the independent investigation was launched, Dr Bill Kirkup said: "I know the death of a child or mother, or their injury during childbirth, is a very distressing event in a family’s life.
"I also know that sharing such experiences can be difficult and traumatic.
"We will listen compassionately and sensitively and will take steps to ensure all families that come forward feel appropriately supported."
Dr Kelli Rudolph’s baby was born in 2016 at the William Harvey Hospital in Ashford, but died five days later.
She has been one of the key witnesses at the Kirkup Inquiry.
Dr Kelli Rudolph says the Trust needs to be held accountable
Archie died 27 minutes after birth at the Queen Elizabeth the Queen Mother Hospital in Margate in 2019.
Speaking after the inquest into Archie's death, Tracey Fletcher, chief executive of East Kent Hospitals NHS Foundation Trust said: “On behalf of the Trust, I apologise unreservedly to Archie’s parents and family for Archie’s death.
“We fully accept the coroner’s findings and conclusion today and we are deeply sorry for the failings in the care provided to Archie and his family in September 2019.
“We have made - and continue to make - changes and improvements to the quality and safety of our maternity service.
“Since Archie’s death, we have made changes to how we care for women and babies during a homebirth, and to how we provide the service when the hospital maternity units are busy.
“The lessons from Archie’s death, and the findings of the independent investigation into our maternity service being led by Dr Bill Kirkup, will be built into our continued improvement, to ensure we provide high-quality maternity care for families in East Kent.”
Last October, the Care Quality Commission (CQC), which inspects hospitals, again expressed concerns over the trust, which it has repeatedly ranked as “requires improvement”.
It said that during unannounced inspections in July 2021 there were not enough midwifery staff and maternity support workers to keep women and babies safe.
Inspectors said staff were feeling exhausted, stressed and anxious, while some community midwives had taken on additional work in the acute units, which meant they were sometimes working 20-hour days.
The families of babies who received poor care at the trust will be the first to read the findings of Dr Kirkup’s inquiry.
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