NHS staff who lie to cover-up poor care in the health service should face a criminal charge, the author of the damming probe into the East Kent maternity scandal has said.
The damning report published yesterday found at least 45 babies died unnecessarily due to 11 years of ‘deep-rooted’ failures in care at East Kent Hospitals NHS Trust.
In total 97 babies and mothers came to significant harm due to ‘deplorable’ care by maternity staff, some with lifelong injuries.
Dr Bill Kirkup noted that this is just the latest maternity scandal to rock the health service and warned that greater change was needed to ‘break the cycle’.
He called for a ‘public service accountability law’ to be introduced so organisations can be prosecuted if they stage cover-ups in future tragedies.
‘It would place a legal duty on public bodies to be truthful and not to conceal problems,’ he said.
The report itself found NHS trusts couldn’t always be trusted to tell the truth when things go wrong and instead focus on ‘reputation management’.
‘The default response of almost every organisation subject to public scrutiny or criticism is to think first of managing its reputation, as is evident from a great many instances within the NHS,’ it reads.
Dr Kirkup also called for a national system to spot worrying trends in NHS hospitals’ maternity data should be established so issues could be detected earlier, and further tragedy avoided.
Dr Bill Kirkup, who led the investigation, warned that such incidents can no longer be seen as a ‘one-off’ and called for a new national system to ‘break the cycle’ of maternity scandals
Bex Walton, who lost her son Tommy when he was two days old, said: ‘Sorry is not good enough’
The mother said she would ‘never be able to forgive’ after loosing her son Tommy (pictured)
Danielle Clark suffered a traumatic birth with her son Noah – now nine – and felt her concerns at at East Kent Hospitals NHS Trust were dismissed
The mother said: ‘Things have got to change. Babies are dying just through bad care and pure neglect’ (pictured: her son Noah when he was just hours old)
The Government, while not responding specifically to Dr Kirkup’s calls for action, said they are taking the recommendations of the report ‘extremly seriously’
Last night, grieving parents also said this must be the last maternity scandal to hit the NHS, while asking why there had not been more outcry about ‘two full classrooms’ of children who never came home.
Dr Kelli Rudolph, whose daughter Celandine died when she was five days old in 2016, said this has to be ‘the end point’.
She said: ‘If in this period of time, a serial killer had killed 45 babies it would be in the headlines from here until the ends of the earth.
‘But 45 babies are dead. It’s one thing to read that, but to sit there and [hear they were] avoidable deaths. What does 45 children look like in a classroom in a school? It’s two full classrooms.’
Danielle Clark suffered a traumatic birth with her son Noah – now nine – and felt her concerns were dismissed because she was a first-time mother. She said: ‘People need to be held accountable. Things have got to change. Babies are dying just through bad care and pure neglect.’
And Bex Walton, whose son Tommy died in 2020, two days after being born at the William Harvey Hospital in Ashford, said: ‘Sorry is not good enough.
‘I will never be able to forgive.’
The harrowing 182-page report was severely critical of the staff who presided over the poor care at the Queen Elizabeth The Queen Mother Hospital (QEQM) in Margate and the William Harvey Hospital between 2009 to 2020.
It described a ‘culture of tribalism’, which included midwives who were ‘bullying and dismissive’ towards mothers.
One woman whose baby had died was told by a member of staff: ‘It’s God’s will; God only takes the babies that he wants to take.’
Another, named only as C, was left bleeding after a traumatic delivery with her family told staff ‘are all in the staffroom having a cup of tea to recover’. The woman’s baby died the following day.
From insolent staff to bosses in denial, probe lays bare baby ward failures
By Kate Pickles Health Editor
The independent inquiry into maternity services at East Kent Hospitals University NHS Foundation Trust heard ‘harrowing’ accounts from families. Its excoriating report found:
UNCARING STAFF
Staff were at the heart of many of the failures. There was ‘a clear pattern’ of staff providing suboptimal clinical care that led to significant harm, failing to listen to families, and acting in ways which made families’ experience unacceptably and distressingly poor.
Families did not just suffer physical harm, with the ‘equally disturbing effects of the repeated lack of kindness and compassion’ by some staff.
LACK OF PROFESSIONALISM
There was a repeated lack of professionalism, where mothers and babies were not put first and often blamed when something went wrong. Staff often put their own needs ahead of the mothers and babies they treated. Some staff were disrespectful and disparaging towards colleagues in front of pregnant women, who would then lose confidence in services as a result. Others sought to deflect responsibility when something had gone wrong, with some mothers blamed for their own misfortune.
A woman admitted to hospital to stabilise her type 1 diabetes pointed out to antenatal ward staff that they were not adjusting her insulin correctly. She was told that ‘we’re midwives not nurses and we don’t deal with diabetes… it’s not our issue and you don’t fit in our box’.
Midwives who were not part of the favoured in-group or ‘A team’ were sometimes assigned to the highest-risk mothers and challenged to deliver babies with no intervention. This was described as ‘a downright dangerous practice’.
LACK OF COMPASSION
The report found many ‘shocking’ examples of uncompassionate care. A woman who asked for additional information on her condition during an antenatal check was told to look on Google. A mother who asked why an additional attempt at forceps delivery was to be made, was brusquely told that it was ‘in case of death’.
Women who said their spinal or epidural analgesia was not effective and they were in pain, were ignored or disbelieved, with one saying ‘they didn’t listen… they carried on, obviously, to cut me open. I could feel it all’.
FAILURES OF TEAMWORK
Gross failures of teamworking across maternity services were found, with problems between the midwives, obstetricians, paediatricians and other professionals involved. Some staff ‘acted as if they were responsible for separate fiefdoms, cultivating a culture of tribalism’.
Divisions among the midwives, including bullying, was to such an extent that the maternity services were not safe.
Some obstetric consultants expected junior staff and locum doctors to manage clinical problems themselves, discouraged escalation, and on occasion refused to attend out of hours.
The report found clear instances where poor teamwork hindered the ability to recognise developing problems.
It said the dysfunctional working between and within professional groups was fundamental to the suboptimal care provided.
The harrowing 182-page report was severely critical of the staff who presided over the poor care at the Queen Elizabeth The Queen Mother Hospital (QEQM) (pictured) in Margate and the William Harvey Hospital between 2009 to 2020
CULTURE OF DENIAL
Senior managers and the trust board knew about problems but put professional reputation ahead of acknowledging the scale of the issues. There was a culture of ‘deflection and denial’ when families sought answers over substandard care. Although no evidence of a conscious conspiracy was found, ‘the effect of these behaviours was to cover up the truth’.
The trust focused on ‘reputation management’ and would often put incidents down to individual clinical error, usually on the part of more junior staff, or to difficulties with locum staff. There was a failure to challenge poor behaviour among midwives and consultants, with some staff left in tears, being shouted at and having things thrown at them. The trust did ‘little to change the poor working culture; instead, it tolerated bad behaviour’.
WHAT ABOUT REGULATORS?
Since 2010, the trust has had the involvement of at least ten external bodies, including the Royal College of Midwives, NHS England, regional managers and the Care Quality Commission.
The inquiry criticised external bodies for failing to take proper action, with numerous missed opportunities dating back to at least 2010. Investigators described ‘a bewildering array of regulatory and supervisory bodies’, but the system as a whole failed to identify the shortcomings early enough to ensure real improvement. Dr Bill Kirkup, chairman of the independent inquiry, said the East Kent report was ‘simply the latest to focus on failings in an individual NHS trust’ with similar harrowing practices dating back to the 1960s, and he called for urgent change.
The obstetrician wants it to become a criminal offence for NHS staff and public sector workers to lie to the public. Dr Kirkup also called for a national ‘maternity signalling system’ to monitor data from all NHS trusts for abnormally high rates of baby deaths. The report identified four areas where urgent action is needed within the NHS: better identifying poorly performing hospitals, ensuring care is given with compassion and kindness, better teamworking, and responding to issues with honesty.
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