At least 45 baby deaths could have been avoided at two Kent hospitals, a report into maternity services at an NHS trust has found.
Dr Bill Kirkup, chair of the independent inquiry into maternity at East Kent Hospitals University NHS Foundation Trust said his panel had heard “harrowing” accounts from families receiving “suboptimal” care.
He said mothers had been ignored by staff and shut out from their own care.
“An overriding theme, raised us with time and time again, is the failure of the trust’s staff to take notice of women when they raised concerns, when they questioned their care, and when they challenged the decisions that were made about their care,” the report said.
The investigation into the care provided to women and babies examined more than 200 cases of poor care dating back to 2009.
It was commissioned in 2020 following growing concerns over the quality of care at the Queen Elizabeth The Queen Mother Hospital (QEQM) in Margate and the William Harvey Hospital in Ashford.
The report found that had they been offered nationally recognised standards of care, the outcome could have been different in 45 of the 65 baby deaths and different in 97 of the 202 cases assessed.
With 33 of those 45 baby death cases, the outcome would reasonably be expected to have been different, while 12 might have been different.
Meanwhile, in 17 cases of brain damage, 12 (72%) could have had a different outcome if good care had been given, of which nine should reasonably have been expected to have had a different outcome.
In nearly half of all cases examined, good care could have led to a different outcome for the families.
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The report described how maternity services were left unsafe due to bullying and “cliquey behaviour” between midwives, with some obstetricians having “challenging personalities … big egos …. huge egos”.
Staff were also “disrespectful to women and disparaging about the capabilities of colleagues”.
One woman whose baby had died was told: “It’s God’s will; God only takes the babies that he wants to take.”
Another could feel herself being cut open due to inadequate pain relief while a new mother worried about her deteriorating baby heard one midwife say to another: “First-time parents.”
The report said midwives who “were not part of the favoured in-group at William Harvey were sometimes assigned to the highest-risk mothers and challenged to achieve delivery with no intervention. This was a downright dangerous practice.”
The report was chaired by Dr Kirkup, who also led the investigation in 2015 into the deaths of mothers and babies at the Morecambe Bay NHS Trust.
In a press conference, Dr Kirkup said a culture of “deflection and denial” within NHS trusts when they are questioned about potential cases of substandard care is a “cruel practice” that “needs to be addressed”.
“This is a cruel practice that ends up with families being denied the truth,” he said.
“That’s a terrible way to treat somebody in the name of protecting your reputation.”
Deborah Morris, whose son Archie was stillborn in 2012, said there was “gross negligence and warning signs and signals” the hospital did not recognise in time.
“I would like somebody to be held accountable for my baby dying because it’s utterly devastating to have to bury your son and I just feel like the hospital has never listened,” she told Sky News.
She said she felt angry the hospitals do not seem to have been held accountable. “As a teacher we have Ofsted who come in and inspect and if we are not doing our jobs properly we’re held accountable to it, and I am really angry with the CQC (Care Quality Commission) for not taking action sooner. They just allowed this to carry on.”
Tracey Fletcher, chief executive of the trust, said: “I want to say sorry and apologise unreservedly for the harm and suffering that has been experienced by the women and babies who were within our care, together with their families, as described in today’s report.
“These families came to us expecting that we would care for them safely, and we failed them.
“We must now learn from and act on this report; for those who have taken part in the investigation, for those who we will care for in the future, and for our local communities. I know that everyone at the Trust is committed to doing that.”
The family of Harry Richford, who died a week after he was born in November 2017, have been campaigning for answers after saying their concerns were repeatedly brushed aside by hospital managers. An inquest ruled his death was “wholly avoidable” and the trust was fined £733,000.