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East Kent Hospitals baby deaths: Investigation finds trust was slow at resolving 'recurrent safety risks'


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A damning report has revealed a hospital trust was "inappropriately slow" at addressing frequent safety concerns on its maternity wards.

A probe into East Kent Hospitals was launched by the Healthcare Safety Investigations Branch (HSIB) following a series of baby deaths, including the "wholly avoidable" case of one-week-old Harry Richford.

The William Harvey in Ashford
The William Harvey in Ashford

The thorough examination found "recurrent safety risks" in 24 cases.

HSIB started its investigation in July 2018 and raised concerns to the trust after discovering widespread problems.

Resuscitation equipment was found to be located in incorrect areas, and questions over staff failures to spot signs of deterioration in health were raised.

The report states: "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.

"Deterioration in the condition of mothers and babies had occurred in several cases because staff had not recognised the signs and symptoms that indicate deterioration.

Sarah and Tom Richford with baby Harry before he died
Sarah and Tom Richford with baby Harry before he died

"As a consequence, clinical interventions that could have prevented further deterioration were missed."

Risks found at maternity wards:

  • Lack of staff with suitable skills in reading and interpreting fetal heartbeat monitor results
  • Lack of guidance to staff on how to recognise results that are of concern or require escalation
  • The location of resuscitation equipment added delay, risk and distress to critical situations. The physical environment on maternity wards was deemed "a barrier to effective and timely resuscitation"
  • Staff responsible for resuscitation were often under supported by appropriately skilled colleagues
  • Staff unable to recognise the signs and symptoms that indicate deterioration in the condition of mothers and babies - this meant clinical interventions that could have prevented further deterioration were missed
  • Concerns over the way problems with complicated births were escalated. The report cites a "reluctance of midwifery staff to escalate concerns to obstetric and neonatal colleagues"

The HSIB says it "engaged frequently" with the trust to present evidence of continued patient concerns.

But despite repeatedly raising concerns, investigators "continued to observe the same risks occurring" at the William Harvey hospital in Ashford and the QEQM hospital in Margate.

'HSIB considers the trust’s early response was inappropriately slow...'

As a result, the trust was asked to refer itself to its Clinical Commissioning Group and the Care Quality Commission watchdog.

The report states: "HSIB considers the trust’s early response was inappropriately slow given the evidence of ongoing patient safety risks and the safety recommendations made.

"The evidence of recurrent and unaddressed safety risks progressively emerged during investigations for the first 10 referred cases. HSIB first raised these particular concerns with the trust in December 2018.

Following repeated calls for action across a number of months, the HSIB says the trust eventually improved its engagement after the involvement of senior clinical teams.

The better communication has led to the implementation of interventions to resolve the safety flaws.

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