Derek Richford, Harry’s grandfather commenting upon repeated maternity investigations at The Baby Lifeline Conference September 2022.

In anticipation of another Kirkup report into the provision of maternity care, this time at East Kent Hospitals University NHS Trust, CL Medilaw look into why lessons are not being learned and where we go from here.

This week, 7 years after producing his report concerning maternity care at Morecombe Bay, Dr Bill Kirkup will be publishing yet another review this time in relation to the provision of maternity services since 2009 under East Kent Hospitals University NHS Trust.

The investigation was triggered by the death of Harry Richford, who died 7 days after his birth on 2nd November 2017, having suffered irreversible brain damage.  The family had to fight hard for an Inquest, with the Hospital Trust refusing to refer Harry’s death to the coroner on numerous occasions reporting that Harry’s death had been expected and there were no delivery complications.  The Coroner concluded that Harry’s death was avoidable.

“The investigation of Harry’s tragic death has not only exposed a number of failures within the East Kent Hospital Trust but has also led to the discovery that deaths of babies within the Trust which should have been referred to the coroner at the time of the death had not been. These concerning events, as the inquest found, should never have happened.”  Patricia Harding, Kent Senior Coroner.

Dr Kirkup and his team have now investigated nearly 200 further maternity cases including deaths of mothers and babies, and babies left with severe brain damage.

The tragedy to each individual family cannot be underestimated and the release of this report, although welcome from the families, can only be traumatic for all those involved and for other parents elsewhere in the country who are concerned about the maternity care they have received.

A long list of reviews

This second Kirkup report is the fourth review since the events at Morecombe Bay.  In 2015 the report into Morecombe Bay followed an investigation of 3 maternal deaths and 16 deaths of babies shortly after birth.  Recommendations called for:-

  • The duty of candour (to be open and honest with patients and people in their care when something goes wrong with their treatment) to be extended to include the involvement of patients and relatives in the investigation of serious incidents;
  • A national protocol for all Trusts to avoid “fending off’ inquests and providing model answers when serious incidents occur.

The report concluded: –

“It is vital that the lessons, now plain to see, are learnt and acted upon, not least by other Trusts, which must not believe that ‘it could not happen here’. If those lessons are not acted upon, we are destined sooner or later to add again to the roll of names.”

Despite this, in December 2020 the Ockendon report reported on major concerns over maternity services provided at Shrewsbury and Telford NHS Trust linked to the death of 201 babies during the delivery and early neonatal period.

More recently news coverage found that dozens of babies have died or sustained brain damage due to maternity errors under the Nottingham University Hospitals NHS Trust leading to a CQC finding of inadequate services. A further review has been announced again led by Donna Ockendon with the report due in March 2024.

Kay Taylor, partner at CL Medilaw commented:-

“It was inspiring to listen to Derek Richford and other parent campaigners at the recent Baby Lifeline Conference in Birmingham, they have fought hard to get these reviews undertaken which can only serve to help other families involved.

However, it is quite unbelievable that this is now the fourth report of its kind in recent years and some core recommendations are still not taken on board consistently by all Hospital Trusts.  We continue to be contacted by families who meet resistance and denial from the Trusts involved.  Being open and honest with families from the beginning, involving them in the process of investigation, accepting mistakes and learning from them is the only way maternity services will evolve and move on from a period where maternity care is so often found to be substandard.  Denial of concerns raised by families can only add to the anguish parents are going through.”

It is hoped that this latest investigation into major concerns regarding the provision of maternity services will increase the pressure to ensure that safer care is provided to mothers and babies, and that future tragedies are avoided as well as encouraging hospitals to be open and honest with families when something does go wrong.

How we can help

If you have concerns about your maternity care and have experienced harm to yourself or your baby, our specialist birth injury team are here to discuss matters with you.

We can offer free specialist advice, even if your case has previously been turned down by other solicitors, and provide you with a second opinion.

Contact us on 0345 2410 154 or click here to request a call back from our friendly team.

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