Kirkup report: 45 baby deaths at East Kent NHS Trust could have been avoided, major inquiry finds

Insufficient care led to the deaths of 45 babies and harm to 97 children and mothers as a result of maternity failings in east Kent, a major report has found.

Dozens of babies died or were left brain damaged by poor care at one of England’s largest NHS trusts, the damning inquiry led by Dr Bill Kirkup has found.

Dr Bill Kirkup, chairman of the independent inquiry into maternity at East Kent Hospitals University NHS Foundation Trust, said his panel had heard “harrowing” accounts from families receiving “suboptimal” care, with mothers ignored by staff and shut out from their own care.

“An overriding theme, raised us with time and time again, is the failure of the trust’s staff to take notice of women when they raised concerns, when they questioned their care, and when they challenged the decisions that were made about their care,” the report 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.

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% 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.

In nearly half of all cases examined by the panel, good care could have led to a different outcome for the families.

During a press conference, Dr Kirkup said a culture of "deflection and denial" within NHS trusts when they are questioned about potential cases of substandard care is a "cruel practice" that "needs to be addressed".

He added: This is a cruel practice that ends up with families being denied the truth.

"That's a terrible way to treat somebody in the name of protecting your reputation."

Responding to the report in a statement from Tracey Fletcher, Chief Executive, East Kent Hospitals University NHS Foundation Trust said: “I want to say sorry and apologise unreservedly for the harm and suffering that has been experienced by the women and babies who were within our care, together with their families, as described in today’s report.

"These families came to us expecting that we would care for them safely, and we failed them.

"We must now learn from and act on this report; for those who have taken part in the investigation, for those who we will care for in the future, and for our local communities. I know that everyone at the Trust is committed to doing that.

"In the last few years we have worked hard to improve our services and have invested to increase the numbers of midwives and doctors, in staff training, and in listening to and acting on feedback from the people who receive our care.

"While we have made progress, we know there is more for us to do and we absolutely accept that. Now that we have received the report, we will read it in full and the Board will use its recommendations to continue to make improvements so that we are providing the safe, high-quality care our patients expect and deserve.

"I want every family – whether they contributed to the investigation or not – to know I am here to listen to them, to learn and to lead our Trust in acting on this report. 

"I would like to thank Dr Bill Kirkup and the investigation team for their work. Today, our thoughts remain with those who have shared their experiences. We are grateful to them.”

Health Minister Dr Caroline Johnson said: “I am deeply sorry to all the families that have suffered and continue to suffer from the tragedies detailed in Dr Bill Kirkup’s review.

“We are committed to preventing families from going through the same pain in future and are working closely with the NHS to continue improving the quality of care for mothers and babies with support teams for trusts, backed by £127 million to grow the workforce and improve neonatal care.

 “We take these findings and recommendations extremely seriously and will review them all in detail ahead of publishing a full response.”

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