East Kent NHS Trust maternity services under review

An inquest held in January concluded that the death of baby Harry Richford at a hospital in Margate in 2017 was “wholly avoidable”. Since then, a number of neonatal deaths at East Kent NHS Foundation Trust have been revealed with several thought to have been avoidable – a harrowing truth for the families that have lost their children.

The Healthcare Safety Investigation Branch (HSIB) is currently investigating 26 maternity incidents at East Kent Hospitals University NHS Foundation Trust, with the oldest dating back to 2011.

What is the Healthcare Safety Investigation Branch?

The HSIB was set up as an independent organisation with a mandate to “conduct independent investigation of patient safety concerns in NHS-funded care across England.” They are responsible for all investigations of maternity incidents that occur, with the aim of improving maternity services in the NHS.

What cases does the HSIB investigate? 

In respect of maternity investigations the HSIB investigates incidents where, following labour babies at a minimum of 37 weeks gestation:

• Are stillborn when they were thought to be alive at the start of labour;
• Die within the first week of life;
• Are born with severe brain injuries

The HSIB will also investigate maternal deaths, unless the death is a result of suicide. Maternal deaths encompass women who are pregnant or who are within 42 days post pregnancy when they die.

What do they do?

HSIB investigations are completed with the aim of addressing failings in maternity care. They include recommendations for changes to be implemented that are tailored to the hospital at which the incident occurred. The aim is that the implementation of their recommendations may improve the Trust’s maternity services and patient safety. Whilst the reports produced by the HSIB may indicate specific failings in a patient’s care, they are not intended to apportion blame.

East Kent Foundation Trust

The concern regarding East Kent Hospitals is so great that it has now been confirmed that NHS England will commission its own independent inquiry into their maternity care.

There has been widespread media coverage in relation to the neonatal deaths at this particular Trust.

Regrettably, I am involved in a number of cases that reflect poor maternity care in a number of Trusts in and around London. Whilst the attention is now focused on the East Kent NHS Trust, more needs to be done by NHS England to ensure that all Trusts are operating with adequately trained staff who are well supported as well as implementing good practices in order to avoid further tragedies in maternity cases.

Maternity safety in England

Promisingly, HSIB also announced this week that it is launching a national investigation into maternity safety across England. This reflects the fact that maternity safety is a concern nationwide and it is to be hoped that this investigation together with the investigation into the care provided by East Kent NHS Trust can lead to improvements in patient safety and prevent avoidable maternity safety incidents in future.