Maternal mortality in East Kent: CQC considered unit closure

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By Christian Fuller, BBC News May 26, 2023 06:16 GMT

Updated 19 minutes ago

Image source, Getty Images

photo caption,

An October review found that at least 45 children may have survived with better care at the secretariat

Health inspectors considered closing the maternity unit earlier this year due to safety concerns.

Instead, the Care Quality Commission called for “immediate improvements” after visiting William Harvey Hospital in Ashford, Kent.

Helen Gittos, whose newborn daughter died in the care of East Kent Hospital, said there were “fundamental” problems with the box.

The CEO of the fund has apologized for his services.

An inspection at William Harvey Hospital in East Kent revealed multiple instances of inadequate practices in the unit, including a failure of staff to wash their hands after each patient, and a failure of life-saving equipment to be in place.

Days after the visit, the watchdog raised safety concerns and the trust threatened enforcement action to ensure patients were protected.

“It’s hard to be reassured.”

Ms Gittus, whose baby Harriet was born at East Kent Trust’s Queen Elizabeth The Queen Mother (QEQM) Hospital in 2014 and died eight days later, said: “When my daughter Harriet was born the then head midwife was so concerned about safety that she thought we should close down.” William Harvey in particular.”

She told BBC Radio 4’s Today programme: “Here we are, almost nine years later, in a similar situation. What was happening just didn’t work out.

“I am still amazed at how shocked I can still be about all this, but I am shocked, because under so much scrutiny, and with so much outside help, it still doesn’t work out.

“The problems that have been revealed are so fundamental that we have to do things differently.”

“We’ve had so many reassurances for so long that until we can see meaningful change coming from them, it’s hard to be reassured, however much I would like it to be,” Ms. Gittos said.

The main findings of the inspectors included the following:

At William Harvey Hospital, inspectors found bloodstains on toilets in day care and triage, inspectors saw “routinely” that staff did not always clean their hands or use aprons and gloves while providing care, residents were not properly in place, were not cleaned and checked not confirmed Staff at the hospital were always unable to get a second opinion, and staff morale was low At both hospitals, at Queen Elizabeth The Queen Mother Hospital, equality and diversity were not always promoted

The BBC’s social affairs correspondent Michael Buchanan said the TQC was considering closing maternity care at the hospital, given the level of concern.

However, the trust promised immediate improvements to care and the CQC eventually decided that weekly monitoring of its services would suffice.

The overall CQC rating for maternity services at both William Harvey and QEQM at Margate decreased from ‘requires improvement’ to ‘inadequate’ after examination.

CQC South operations director Diana Westwood said the agency has now used “urgent enforcement powers” to “request immediate improvements” in the fund.

The CQC highlighted particular concerns about the use of resuscitation equipment.

“Babies requiring emergency resuscitation were moved to a resuscitator – however, in some cases, they were outside the labor room and in the corridor,” Ms Westwood said.

“This can lead to delays in vital neonatal care and treatment, as well as separation from the mother and an increased likelihood of infant misidentification.”

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Trust CEO Tracy Fletcher

Tracy Fletcher, chief executive of East Kent Hospitals, said: “I am sorry that despite the commitment and hard work of our staff, when they carried out an inspection in January the CQC found that the trust was not consistently providing the standards of maternity care to women and families should expect.”

Confidence has since increased from the staff of doctors at the William Harvey Triage Service, she said. The Secretariat also said it had ensured better access to emergency equipment and improved cleaning.

Ms Fletcher added: “We recognize that despite the changes that have been made to the service to date, much more needs to be done to ensure that we consistently deliver high standards of care to every family, every time.”

The independent October review, which was chaired by Dr Bill Kirkop CBE, examined an 11-year period from 2009 at the two hospitals.

It found that of the 202 cases examined, as many as 45 children could have survived if they had received better care from the Trust.

The review revealed a “clear pattern” of “suboptimal” care that led to significant harm, and said families were being ignored.

“There must be a girl of nine years old with me, getting ready for school,” said Mrs. Gittos, “and I wish she was there.”

analysis

By Mark Norman, BBC South East health correspondent

It’s another terrible report from the inspectors.

More condemnation of managers and reminders that the trust does not have enough maternity staff or medical staff with the appropriate qualifications, skills, training and experience.

But two things concern me.

This inspection came two months after Dr. Bill Kirkop’s report was published. It begs the question why senior managers did not initiate simple safety changes in the weeks following this report.

Secondly, NHS England has had ‘Maternity Improvement Advisers’ supporting the trust for the past four years. It is worrying that with so much support and vetting, these issues are still there and they don’t seem to be getting any better.

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