Our hearts go out to all of the families and people affected by the East Kent Hospitals NHS Trust Maternity failings.
Dr Bill Kirkup conducted an independent study of the Trust beginning 13 years ago in 2009.
The report has investigated the trust's maternity services over an 11-year period from 2009 to 2020.
The BBC investigate the history of the issue and why it has taken over a decade to be fully uncovered.
The inquiry published on 19th October 2022, reveals dozens of families suffered and some lost their babies because of NHS Maternity failings.
The harrowing report has found:
Gross failures in team working, with a serious of problems between midwifes, obstetricians, paediatricians and neo-natal services
“Dysfunctional team working” and poor behaviour clouded the response to safety incidents
Repeated failures to listen to families
Problems among the midwifery staff and obstetric staff were known but not addressed
Regulatory system failed to identify shortcomings early enough and clearly enough
East Kent Hospital Baby Deaths: Dr Bill Kirkup’s review.
The probe, led by Dr Bill Kirkup, was commissioned by the government after it was revealed that more than 130 infants suffered brain injuries during birth at the trust over several years.
Dr Kirkup said his panel had heard “harrowing” accounts from families receiving “suboptimal” care, with mothers ignored by staff and shut out from their own care.
He told a press conference that there was a "substantial amount of anger" among families of those affected by failings in maternity care at the Trust.
"What has happened in East Kent is deplorable and harrowing," said Dr Kirkup.
"In 45 of the 65 stillborn and newborn babies who died, there could have been a different outcome."
"Unkind and callous" behaviour was shown towards mothers and families, and this has "deeply affected" them, he said.
There was a culture of treating patients "rudely, arrogantly and with hostility". One mother, who lost her baby, was told that it was "God's will", the review found.
Maternity staff are accused of 'blaming mothers for the deaths of their babies'
Dr Kirkup also said there were "extreme failures of teamworking". "A team that works to different goals, in my view, is not a team," he said.
Of 202 cases reviewed by the experts, the outcome could have been different in 97 cases, the inquiry found.
In 69 of these 97 cases, it is predicted the outcome should reasonably have been different and could have been different in a further 28 cases.
Of the 65 baby deaths examined, 45 could have had a different outcome if nationally recognised standards of care had been provided (69.2 per cent).
When looking at 33 of these 45 cases, the outcome would reasonably expected to have been different, while in a further 12 cases it might have been different.
Meanwhile, in 17 cases of brain damage, 12 (72 per cent of cases) 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.
Inspections last year found staff working 20-hour shifts in a desperate bid to cover shortages. They also warned of “horrific” morale among junior doctors, with some afraid to come to work because they felt out of their depth, and unable to get help from senior medics.
Reports found staff 'failed to listen to families'.
More than 200 families gave evidence to the review which has exposed a catalogue of serious failings including how newborns died needlessly due to poor care planning over several years, while parents' concerns were ignored.
The Government is expected to respond today in the Commons to the report, which was commissioned by NHS England in 2020 following growing concerns about quality of care.
This morning the now former governor of East Kent Hospitals University NHS Foundation Trust Alex Lister resigned over his role in the maternity scandal.
In a letter to trust chairman Niall Dickson, Mr Lister said his decision to resign was not taken lightly.
He said: 'While there have been some positive changes in leadership including your appointment as chair and the appointment of a new chief executive, there remains a cancer at the top of the organisation.
'I believe officials on six-figure salaries continue to mislead, obfuscate, bully and conceal vital information.
'Without the valiant efforts of the brave families caught up in a tragedy of the Trust’s making, the world may never have found out about the disastrous health failings at our Trust.
'Yet, despite everything we now know, individuals complicit in the attempted cover-up of the maternity scandal, including the tragic case of baby Harry Richford, continue in their positions.'
These failures can lead to outcomes that have a devastating, life-changing impact on the families involved. Those families deserve answers and urgent changes to hospital culture and maternity services must be made so that no more families suffer.
If you think you have been affected by substandard maternity treatment you should seek the opinion of one of our expert solicitors as soon as possible. You may be able to bring a claim for medical negligence against the hospital that treated you and your baby during your pregnancy and labour.
We understand the devastating impact these events have on mothers and their families and we are keen to get families the answers that they deserve.
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With no win no fee, there aren’t any upfront charges or hidden costs. If you do win your case, we will charge you a ‘success fee’ as a percentage of the compensation you receive, this will then be capped at a maximum of 25% – and in many cases this is significantly less than this so you will receive the majority yourself. This fee will be agreed between you and your solicitor before we take on your case.
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