Grieving families will hear the results of a report into maternity failings at East Kent Hospitals today.
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 families were often ignored or had their concerns overlooked, while valuable lessons were not learned by the trust.
Speaking today, author of the report Dr Bill Kirkup called for a fresh approach to NHS maternity care saying "this cannot go on".
The Government is expected to respond on Wednesday to the report, which was commissioned by NHS England in 2020 following growing concerns about quality of care.
In total, more than 200 cases dating back to 2009 have been looked at by an expert panel chaired by Dr Bill Kirkup, who also led the investigation into mother and baby deaths in Morecambe Bay in 2015.
East Kent runs major hospitals, with its main maternity services at the Queen Elizabeth The Queen Mother Hospital (QEQM) in Margate and the William Harvey Hospital in Ashford.
The family of baby Harry Richford, who died a week after his birth at the QEQM in 2017, have long campaigned for answers after saying their concerns were repeatedly brushed aside by hospital managers.
The trust was fined £733,000 last year for failures in Harry's care after he suffered brain damage.
A previous inquest ruled his death was "wholly avoidable" and found more than a dozen areas of concern, including failings in the way an "inexperienced" doctor carried out the delivery, followed by delays in resuscitating him.
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.
Only the efforts of Harry's family eventually brought his death to the attention of coroner Christopher Sutton-Mattocks.
Speaking today (19 October) ahead of the report's publication, Dr Kirkup said he “did not imagine” he would be talking about similar circumstances again following his investigation into Morecambe Bay in 2015.
He told BBC Radio 4’s Today programme: “When I reported on Morecambe Bay maternity services in 2015, I did not imagine for one moment that I would be back in seven years’ time talking about a rather similar set of circumstances and that there would have been another two large, high-profile maturity failures as well on top of that.
“This cannot go on. We have to address this in a different way.
"We can’t simply respond to each one as if it’s a one-off, as if this is the last time this will happen. We have to do things differently.”
Dr Kirkup revealed the expert panel investigating had heard "harrowing accounts" from families during their work.
He added: "We’ve heard from a lot of families, a lot of harrowing accounts. I’ll be setting all of that later for the families first and then for everybody, but there were a lot of common factors.
“My heart goes out to everybody that this has happened to."
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.
In 2020, the Healthcare Safety Investigation Branch (HSIB), which investigates NHS harm, detailed how, despite repeated warnings from its investigators, improvements were not made to maternity care at the trust.
The HSIB began working with East Kent's maternity units in 2018 and identified "recurrent safety risks" including over how CTG readings were interpreted, baby resuscitation, recognition of deterioration in mothers and babies, and the willingness of staff to escalate their concerns to more senior medics.
From December 2018, the HSIB said it "engaged frequently" with the trust about its concerns but kept seeing the same things happening.
In August 2019, it asked the trust to self-refer to the CQC and regional health bosses.
The families of babies who received poor care at the trust will be the first to read the findings of Dr Kirkup's inquiry.
Among them are expected to be the parents of Archie Batten, who died in September 2019 at the QEQM.
A coroner ruled he died of natural causes "contributed to by neglect" and "gross failure".
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