Hospital hit by baby death scandal did not have enough staff to keep patients safe, inspectors find

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Hospital hit by baby death scandal did not have enough maternity staff to keep patients safe with some midwives forced to work 20 hour shifts, inspectors find

  • Staff were offered money to work 20-hour shifts due to COVID  staff shortages 
  • 15 babies have died in the care of East Kent Hospitals Trust since 2011 
  • The findings come after unnanounced inspections into the maternity services
  • The trust was so short-staffed that women had to be moved to different hospitals during labour


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A hospital at the centre of a baby death scandal did not have enough maternity staff to keep mothers and babies safe, inspectors have found.

The Care Quality Commission found staff numbers were so low at East Kent Hospitals Trust that midwives were forced to work 20 hour days with little time for a break.

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It found that the shortages meant women were transferred to other hospitals during labour, with not enough staff with the right qualifications or training to keep women safe from ‘avoidable harm’.

Two reports were compiled following unannounced inspections in July of maternity units and children and young people’s services at the Queen Elizabeth The Queen Mother Hospital in Margate and William Harvey Hospital in Ashford, and the community midwifery services at Kent and Canterbury Hospital in Canterbury and Buckland Hospital in Dover.

Since 2011, 15 babies have died in the care of East Kent Hospitals NHS Trust

Since 2011, 15 babies have died in the care of East Kent Hospitals NHS Trust

Among the failings, inspectors found that staff often had to care for two women at once, and the telephone service for advice during the pandemic had received so many calls that non-clinical staff with limited experience were answering and assessing women who were phoning in.

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They also found that community midwifery teams did not visit all new mothers and their babies at home, instead carrying out telephone assessments.

Concerns were initially raised about maternity services at the trust after a coroner ruled the death of week-old Harry Richford at Margate’s Queen Elizabeth the Queen Mother Hospital (QEQM) to be ‘wholly avoidable’.

Harry Richford, pictured with his parents Sarah and Tom, died at just seven days old while in the care of East Kent Hospitals NHS trust

Harry Richford, pictured with his parents Sarah and Tom, died at just seven days old while in the care of East Kent Hospitals NHS trust 

Since then an independent review was commissioned by the government after more families came forward about their experiences.

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Inspectors did however praise the trust for the improvements it had already put in place, raising its rating from ‘inadequate’ to ‘requires improvement’. 

Amanda Williams, the CQC’s head of hospital inspection, told the BBC: ‘When we inspected the maternity services, we were concerned that there were not enough midwifery staff and maternity support workers to keep women and babies safe.

‘We were also concerned that some staff were feeling exhausted, stressed and anxious, because mistakes can easily be made when people’s judgement is impaired by fatigue.’

Harry (pictured with his parents in hospital) died after an emergency C-section

Harry (pictured with his parents in hospital) died after an emergency C-section

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Ms Williams said: ‘Staff did not always take the time to report all incidents around staffing and capacity issues. Staff felt that continually reporting short staffing had not improved the situation.’ 

The trust has reiterated its commitment to providing a high quality of care to patients.  

Sarah Shingler, chief nursing officer at the trust told the BBC she was glad the CQC had pointed out areas of improvement for the trust after it had to deal with staff shortgaes caused by the pandemic.

Shingler added: ‘We continue to work hard to support our midwives’ wellbeing and help them provide a safe, high quality service for women and babies.

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‘This includes a £1.6m investment to fund an additional 38 additional midwives with 26 already in post’.

What were the alleged failings at East Kent NHS? 

The trust at the centre of a scandal over baby deaths failed to deliver Harry Richford on time, 92 minutes after an expert advised he should be.

Harry died at just seven days old after being delivered by C-section on November 2 2017. 

The QEQM also gave Mrs Richford a drug to speed up labour, which hyper-stimulated the infant. 

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Archie Batten died on September 1 2019 shortly after being born. His mother had called QEQM to say she was in labour.

But she was told the maternity unit was closed and to drive herself to the trust’s other hospital, Ashford’s William Harvey, 38 miles away.

Four midwives went to her home after the journey was deemed not feasible but they struggled to deliver the baby.

The mother was transferred by ambulance to QEQM, where her son died. His inquest in scheduled for March.   

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Archie Powell died at four days old on February 14 2019 after medics treated the twin for a bowel problem.

They failed to spot he had a common infection despite him showing all its symptoms and the delay in treatment sparked severe brain damage.

Tallulah-Rai Edwards was stillborn on January 28 2019. Her mother had become anxious in the 36th week of pregnancy due to her baby’s slowed movement and went to hospital.

Despite struggling to get a good heart-rate reading on the cardiotocography (CTG) machine, midwives sent her home. The baby was found to have died two days later when her mother returned to the hospital.

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Hallie-Rae Leek died aged four days old on April 7 2017. A midwife had struggled to find a heart-rate and she was born in a poor condition.

She was resuscitated after 22 minutes but the damage was irreparable.  

There were two stillbirths at the trust in 2016, in March and June. In the first case, the unit failed to recognise that an infant was small given the stage of development. They did not act on suspicious CTG readings and failed to deliver the baby promptly.

In the second case, the trust missed risk factors and failed to properly monitor a CTG and a baby girl died. 

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