By Kathy Bailes / Ping News

A national task force is to be set up in response to the baby deaths scandal at East Kent Hospitals.

It will review “maternity and neonatal improvement programmes” across the country.

The task force is being created in response to an independent investigation into maternity failings at the QEQM, in Margate, and the William Harvey, in Ashford, which found 45 baby deaths could have been avoided.

It will be chaired by the minister for women’s health strategy, Maria Caulfield MP.

She announced the measure as part of the government’s response to the inquiry carried out by Dr Bill Kirkup and his team.

NHS England and NHS Improvement commissioned Dr Kirkup in 2020 to carry out an independent review into the circumstances of the maternity deaths at the East Kent Hospitals Trust sites in response to a concerning number of avoidable baby deaths.

Issues with maternity were brought into the spotlight following the death of baby Harry Richford at the QEQM in 2017 after a series of errors.

An independent report said he might have survived had there not been a delay in resuscitation at his birth that caused irreversible brain damage.

Some 200 families came forward to the Kirkup review over the preventable deaths of their babies.

The Kirkup report found that between 2009-2020, the timeframe under review, “those responsible for the services too often provided clinical care that was suboptimal and led to significant harm, failed to listen to the families involved, and acted in ways which made the experience of families unacceptably and distressingly poor”.

The panel found that had care been given to the nationally recognised standards, the outcome could have been different in 97 (48%) of the 202 cases assessed. The outcome could have been different in 45 (69%) of the 65 baby deaths.

Numerous other failings were highlighted in the review.

Now Ms Caulfield has announced new measures which will also include a local forum to oversee progress at East Kent Hospitals Trust.

The task force will bring together key people from the NHS and other organisations to look at the work to improve maternity and neonatal care.

Dr Kirkup will also work with healthcare partners to help ensure teams in maternity and neonatal care across England can work together to ensure compassionate care is provided.

Included in the five recommendations is that “the government reconsiders bringing forward a bill placing a duty on public bodies not to deny, deflect and conceal information from families and other bodies”.

It also suggest “Trusts be required to review their approach to reputation management and to ensuring there is proper representation of maternity care on their boards”.

The recommendations

1. The prompt establishment of a task force with appropriate membership to drive the introduction of valid maternity and neonatal outcome measures capable of differentiating signals among noise to display significant trends and outliers, for mandatory national use.

2i. Those responsible for undergraduate, postgraduate and continuing clinical education be commissioned to report on how compassionate care can best be embedded into practice and sustained through lifelong learning.

2ii. Relevant bodies, including royal colleges, professional regulators and employers, be commissioned to report on how the oversight and direction of clinicians can be improved, with nationally agreed standards of professional behaviour and appropriate sanctions for non-compliance.

3. Relevant bodies, including RCOG, RCM and the Royal College of Paediatrics and Child Health, be charged with reporting on how teamworking in maternity and neonatal care can be improved, with particular reference to establishing common purpose, objectives and training from the outset.

4i. The government reconsiders bringing forward a bill placing a duty on public bodies not to deny, deflect and conceal information from families and other bodies.

4ii. Trusts be required to review their approach to reputation management and to ensuring there is proper representation of maternity care on their boards.

4iii. NHSE reconsiders its approach to poorly performing trusts, with particular reference to leadership.

5. That the trust: accepts the reality of these findings; acknowledges in full the unnecessary harm that has been caused; and embarks on a restorative process addressing the problems identified, in partnership with families, publicly and with external input.

‘They need to do better – for the sake of my daughter and so many others’

Among those affected were Helen Gittos and Andy Hudson who said they were “treated dismissively, contemptuously and without a desire for understanding” throughout pregnancy, labour and then the tragic death of their baby Harriet.

Harriet was born on August 3, 2014, at the QEQM and died just days later on August 11. Her case was one of those reviewed in a Royal College of Obstetricians and Gynaecologists review of the service in 2015. Harriet was a full-term baby and healthy but died after sustaining a brain injury during her birth.

In response to the government statement accepting the recommendations in Dr Kirkup’s report – Reading the Signals – Helen told the Isle of Thanet News: “I am delighted Maria Caulfield has accepted the recommendations of the report, that she will personally chair an oversight group to ensure they are implemented, and that she has enlisted Bill Kirkup’s help.

“It’s also heartening that the Department recognize the seriousness of the ongoing problems at East Kent. But it is hard to see that further scrutiny will help, even at ministerial level. A decade of scrutiny hasn’t helped.

“Locally and nationally we need strong clinical leadership. And a means to hold people to account when they persist in behaving unprofessionally. We also need fewer organisations and initiatives and, instead, on the model of Reading the Signals, a focus on key changes that will make things better for all of us.

“On the first recommendation, about better statistical tools for identifying problems, good progress has been made, with a draft promised in the autumn.

“But the detailed discussion of the other recommendations embodies the very things that hamper progress: it’s a morass of initiatives, mostly in the past, made by a large and disparate number of bodies. And it often misses the point.

“The proposals for Recommendation 2, about compassionate care and accountability, contain nothing substantive. The consideration of Recommendation 3 misses the core issue about the need for doctors and midwives to agree common objectives that inform education and training for both professions.

“For Recommendation 4, about cover up, the Home Office needs to publish the Public Accountability bill. And surely NHS Resolution should accept the findings of Bill Kirkup’s report.

“Maria Caulfield and Bill Kirkup will need to cut through vested interests and inertia to do better than this - for the sake of my daughter Harriet – and for so many others.”

Maternity services rated inadequate

In May the Care Quality Commission (CQC) told East Kent Hospitals Trust that it must make immediate improvements to its maternity services following an inspection in January which saw the service’s rating drop from requires improvement to inadequate.

Following the CQC report, chief executive Tracey Fletcher said the Trust had responded immediately to safety concerns, adding: “We recognise that, despite the changes that have been made to the service so far, there is a lot more to do to ensure we are consistently providing high standards of care for every family, every time.

“We are continuing to work hard to improve the culture and multi-professional teamworking highlighted by Dr Bill Kirkup through the independent investigation into our maternity services, including implementing ‘civility saves lives’ staff training. I am grateful to the families who are helping us as we seek to make these improvements and to our staff, for their commitment.”