Nick Fairweather give his response to the Kirkup Report

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19th October 2022 – Fairweathers Solicitors have represented around two dozen families whose babies died or were caused severe injury with lifelong disabilities due to the failings of East Kent Maternity Services.

Here our CEO and Head of Clinical Negligence, Nick Fairweather, gives his response to the findings and report of Dr Bill Kirkup and his team following their investigation into maternity services provided at the Trust spanning 2009 through to 2020:-

“This report shines a bright light into the darkest corners of this Trust’s operations over so many years. The longstanding and deep-rooted problems with maternity services in East Kent were highlighted long ago by many as highlighted by the Report. These include the Royal College Of Gynaecologists back in February 2016 when they reported in depth on the problems they found when they were asked to audit the department by the local Clinical Commissioning Group. The problems they uncovered and the remedial action needed were converted into a Corporate Risk Report, by the Trust, known as CRR26, in May 2016. However, this Risk Report was downgraded, then amalgamated with another CRR and had its implementation dates continuously pushed backwards.

The Trust management’s attitude was that they knew best and this was a belief shared by some of the leading people in the clinical team.

We have seen a systematic cover up of failings through misleading families, inferring that mothers were to blame for deaths or adverse consequences and shielding the Trust from external scrutiny by regulators and indeed the Coroner.

Small wonder that today we see so many families who have suffered due to the failings highlighted by the RCOG going unchecked and with the changes needed way back then not being properly implemented.

This was atrocious management at a senior level which fostered and cultivated a culture of superiority and denial. Mistakes can happen in the best run hospitals. What is crucial is that they are identified, that patients are given honesty and that, above all, everybody works extremely hard to ensure that the same mistakes are not repeated.

None of these things have happened at East Kent, quite the opposite.

Indeed I am struck by the range of failings represented in the cases brought by the families that we represent.

These cover the whole journey from pregnancy through to delivery, antenatal care and dealing with paediatric emergencies.

We have seen, in our cases, systemic and individual errors which have included:-
the Trust having a very low threshold for putting their maternity services at the QEQM in total lock down, unbelievably bad record keeping, appalling communication, an over reliance on junior doctors and staff, locums being engaged without any proper scrutiny and induction then deployed well beyond their competency levels, distrust between different clinical practitioners and specialisms, crucial test results during pregnancies being overlooked, mis- readings of CTG traces, failures to escalate, senior clinicians failing to attend emergency presentations, delays in transfers in emergency situations, bungled deliveries, truly egregious examples of failing to intubate newly born babies, delays in taking families’ concerns seriously post – delivery and to treat neonate infections, repeated failures to follow their own and national guidelines, a failure to recognise, admit and report on errors accurately or at all,.

The Trust has repeatedly apologised for its errors and represented to the families and the
wider public that it is determined to learn from its mistakes and improve its services.
The experience of our families, however, has all too often been one of the Trust completely lacking transparency and candour and still looking to avoid proper scrutiny on an ongoing basis.

As recently as February this year, for example, the Trust and all 4 midwives who caused Archie Batten’s death in September 2019 suddenly petitioned the Coroner in unison to abandon her Inquest investigation and not hold the hearing finally listed for March at all on the spurious grounds that Archie was still born.

That application got short shrift from the Coroner who duly held a very detailed 2 week hearing finding that Archie died unnecessarily through neglect [click here to see article].

Even now the Trust unreasonably refuses to mediate to try to settle Vasile Gavrilescu’s case arising from the death of his son Luchii back in 2019, long after the Coroner found [click here to see article] that it was caused by admitted failings in their care of Vasile himself [click here to see article].

Where Are They Now?

CEO Susan Acott has disappeared in recent times and I think the public deserve to know whether she was given a pay-out as she left?

All four midwifes who were so incompetent and cost Archie Batten his life are still employed, impossible to displace with the Midwifery Council apparently unable or unwilling to intervene meaningfully.

The Obstetricians and Neonatologist who bungled Harry Richford’s delivery and resuscitation continue to practice without meaningful intervention by the GMC.

We have fresh cases today showing that the Trust’s recruitment practices remain flawed

The Future

The regulatory bodies are well past their sell by date in my opinion.

The GMC are far too slow to act decisively or at all.

Too often they look to exculpate practitioners who are not fit to practice and so the same mistakes are made again and again.

The NMC seem incapable of early and decisive action and put practitioners rather than patients at the heart of their operations.

The work that maternity doctors and midwifes do is absolutely priceless and when done properly they deserve our huge gratitude, credit and full support.

The fact of the matter, however, is that incompetent people in key positions are dangerous and far too many of those who made the key individual mistakes are still employed by the Trust and elsewhere impervious to proper regulation or direction in relation to their work.

I agree with Derek Richford that we need one super regulator to replace the myriads of competing and overlapping regulatory bodies with proper powers to intervene when Trusts are operating dangerously as an organisation systemically or on account of incompetent individuals.

In terms of Dr Kirkup’s key findings they are unflinching, with possibly 45 needless baby  deaths, 12 cases of severe brain injury and 23 unnecessary maternal deaths. Further his candid and chilling assessment that the Panel have seen no discernible improvements up until 2020 makes for difficult reading. I am struck by the similarities with Morecombe Bay and the 2015 report from Dr Kirkup, as I know he is.

I hope that this Report’s Key Recommendations are adopted and implemented effectively and bring the lasting change that the families, led by Derek Richford, have fought for and so deserve as a lasting tribute to their loved one’s lost.”

Nick Fairweather

If you or your family need the assistance of an experienced team of Clinical Negligence Solicitors surrounding an inquest or civil claim then please do not hesitate to phone us free on 0800 999 5585, request a call back or submit your case details.