East Kent maternity deaths: New mum recalls horror of birth

By Michael Buchanan & Christian Fuller

Social affairs correspondent, BBC News

A first-time mother told how she was left in bloody sheets for three days at a maternity unit that was nearly shut down in January over safety concerns.

Philippa Chapman said staff refused to clean her bed after she had given birth at the William Harvey hospital in Ashford, Kent, in March last year.

She said the birth was “horrendous”, and she would not return to the unit as she would fear for her life.

The trust apologised to Mrs Chapman and for its wider failings.

Mrs Chapman recalled her harrowing ordeal after it emerged that health inspectors considered shutting down the William Harvey’s maternity unit earlier this year over safety concerns.

The Care Quality Commission instead called for “immediate improvements” following a visit.

The watchdog’s inspection came weeks after a review in October found at least 45 babies might have survived at the two hospitals run by the East Kent Hospitals Trust.

After Mrs Chapman went into labour, she asked for an epidural, but was told there were no staff around to help her.

She said she was told she would need to “wait until either your life is in danger or his (her son) life is in danger before we can bump you up the queue. It was horrific”.

Her son, Ambrose, was born hours later after an episiotomy. But shortly after his birth, he developed jaundice and both mother and baby had to stay in the William Harvey for five days.

However, Mrs Chapman was left in blood-stained sheets for three days, despite asking for clean bedding.

“I was still in the sheets that they’d done the episiotomy on,” she said.

The inspection of East Kent’s William Harvey hospital laid bare multiple instances of inadequate practices at the unit, including staff failing to wash their hands after each patient, and life-saving equipment not being in the right place.

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

Helen Gittos, whose newborn daughter died in the care of the East Kent Hospitals Trust, said there were “fundamental” problems at the trust.

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

She told BBC Radio 4’s Today programme: “Here we are, almost nine years later, in a similar kind of situation. What has been happening has not worked.”

The inspectors’ key findings included:

• At the William Harvey hospital, inspectors found bloodstains on toilets
• In day care and triage, inspectors “routinely” saw staff did not always clean their hands or use aprons and gloves while delivering care
• Resuscitaires were not available in the right place, nor were they cleaned and checked regularly
• Staff at the hospital did not always ensure a second opinion was sought
• Staff morale was low across both hospitals
• At The QEQM, equality and diversity were not always promoted

After it was threatened with closure by the CQC, the trust promised to make immediate improvements to care. The CQC ultimately decided that weekly monitoring of its services would suffice.

The overall CQC rating for maternity services at both the William Harvey and The QEQM in Margate has dropped from ‘requires improvement’ to ‘inadequate’ following the inspection.

Deanna Westwood, the CQC’s director of operations south, said the watchdog has now used “urgent enforcement powers” to “require immediate improvements” at the trust.

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

She said the trust has since increased doctor staffing in the triage service at William Harvey. The trust also said it has ensured better access to emergency equipment and improved cleaning.

Ms Fletcher also said she was “truly sorry” for Ms Chapman’s experience.

“I am committed to making the improvements needed to ensure we are consistently providing high standards of care for every family, every time. I am sorry that this was not the case for Philippa,” she said.

Niall Dickson, chair of the trust, said: “This is a sobering and highly critical report.”

He told the BBC’s Today programme: “We knew that some of this would take time, but this report underlines both how much more we need to do, but also frankly we need to concentrate on the basics.

“There’s a new director of midwifery and her deputy, who have both come from outstanding trusts, and I know their focus is on getting those basics right and getting those basics in place.”

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

It found that of the 202 cases that were examined, up to 45 babies might have survived if they had received better care from the trust.

The review uncovered a “clear pattern” of “sub-optimal” care that led to significant harm, and said families were ignored.

Ms Gittos said: “There ought to be a nine-year-old girl with me, getting ready for school, and I wish there were.”

By Mark Norman, health correspondent, BBC South East

It is another awful report from inspectors.

More condemnation of managers and a reminder that the trust doesn’t have enough maternity staff or medical staff with the right qualifications, skills, training and experience.

But two things concern me.

This inspection came two months after the publication of Dr Bill Kirkup’s report. It begs the question why simple safety changes had not been initiated by senior managers in the weeks following that report.

Secondly, NHS England have had “maternity improvement advisors” supporting the trust for the last four years. It’s worrying that with a huge amount of support and scrutiny that these problems still exist and don’t appear to be improving.

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