The Kirkup Inquiry
The Kirkup Independent Inquiry into maternity services in East Kent was commissioned by Sir Simon Stevens, CEO of NHS England in April 2020 following Harry's inquest and reports commissioned by Health Minister Nadine Dorries MP from the CQC and HSIB.
This speech to Baby Lifeline by Derek Richford was made 4 weeks before the Kirkup report and with no sight of the report - HERE it has proved to be entirely pertinent and accurate. Here, the BBC tell Harry's story from a grandfathers perspective HERE
Carole Malone from The Express Comments HERE - No Consequences for NHS Staff Who Kill Babies
You can see Dr Kirkup's press conference in full here - PRESS CONFERENCE
Here is a detailed breakdown of the history of East Kent issues - Minh Alexander's Report
Channel 4's Victoria McDonald - REPORT HERE
You can download the report into East Kent here -Kirkup Report it is truly shocking what went on before and AFTER Harry's death.
Missed Opportunity 7: The death of baby Harry Richford
1.103 Baby Harry Richford died on 9 November 2017 in the neonatal unit at WHH in Ashford, seven days after he was delivered at QEQM in Margate. The cause of death was recorded as hypoxic ischaemic encephalopathy (HIE).
1.104 Many of the same red flags that had shown themselves in the litany of previous inspections, reviews and reports appear again in baby Harry’s case. Not only does this apply to the clinical care given to his mother, Sarah Richford, it is also evident in the way that the whole family were treated after his death. The patient safety issues echoed the problems that had been highlighted first in the Trust’s internal review of 2010 and most recently again in the RCOG report, published 18 months before Sarah attended QEQM.
1.105 Sarah witnessed conflict and disagreement between the obstetric and midwifery teams about the way that oxytocin was being used to augment her labour. Midwives were concerned about changes to the continuous heart trace of the baby, but the obstetric team disagreed.
1.106 Obstetric cover on the labour ward was provided by a locum specialist registrar, whose knowledge and experience had not been assessed by a Trust consultant. When there was disagreement over Sarah’s care plan, neither the locum registrar nor the midwifery team escalated this to the consultant on call, contrary to guidelines. Sarah was not reviewed by an obstetric consultant during either the 1pm or 6pm assessment rounds, contrary to unit protocols.
1.107 There were further features of concern over the baby’s condition coming up to delivery, and the locum registrar undertook to expedite delivery, either by forceps delivery or, if this was not possible, by a caesarean section. It appears that the locum registrar discussed this by telephone with the consultant on call, who agreed with the plan but did not attend, although it was likely to present challenges to an inexperienced obstetrician.
1.108 After an unsuccessful attempted forceps delivery, a caesarean section was undertaken. Unsurprisingly, in view of the descent of the baby’s head, this proved very difficult; several attempts were made to dislodge the head from the pelvis, including by applying pressure vaginally. The consultant on call was contacted by telephone and offered advice but was still not in attendance.
1.109 There were major difficulties in resuscitating baby Harry after delivery, including delay in establishing an airway, together with delay in escalating concerns to a consultant paediatrician on call.
1.110 In keeping with the familiar pattern of downplaying problems and seeking to avoid external scrutiny, the Trust classified baby Harry’s death as “expected” on the basis that he was admitted to the neonatal unit at WHH with severe HIE, and therefore death was not an unexpected outcome. For that reason, the Trust initially refused to refer baby Harry’s death to the coroner for investigation. There were errors in the data sent to the national audit, Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK).
1.111 Baby Harry’s family faced great difficulty in finding out what had gone wrong, although they were sure that something had, and they began to distrust any information they received from the Trust. The weeks, months and years that followed baby Harry’s death involved sustained efforts by his family to seek understanding and truth about what had happened during his delivery. Their efforts included referring the case to HSIB and to the CQC for investigation and pressing to have a full inquest into the circumstances of his death.
1.112 This pattern of behaviour by the Trust, clearly evident in this case, recurred in many others that we examined. It included denying that anything had gone amiss, minimising adverse features, finding reasons to treat deaths and other catastrophic outcomes as expected, and omitting key details in accounts given to families as well as to official bodies. Although we did not find evidence that there was a conscious conspiracy, the effect of these behaviours was to cover up the truth.
1.113 Even had none of the previous failings been known – and they were – baby Harry’s death should surely have been a catalyst for immediate change. In fact, it required public remonstration by a coroner over two years later, precipitated by the persistence, diligence and courage of baby Harry’s family, to reveal an organisation that did not accept its own failings, considered itself above scrutiny or accountability, and consistently rejected the opportunity to learn when things went wrong.
Dr Bill Kirkup's report into the Morecombe Bay maternity scandal can be read here - Morecombe Bay and says -
This Report sets out why that is and how it could have been avoided. It is vital that the lessons, now plain to see, are learnt and acted upon, not least by other Trusts, which must not believe that ‘it could not happen here’. If those lessons are not acted upon, we are destined sooner or later to add again to the roll of names."
BILL KIRKUP CBE - March 2015
The same things were happening in East Kent, but they were in total denial.
Here are just a few examples, sadly there are hundreds - any emphasis by bold or underline is our emphasis.
1.2 We have found a clear pattern. Over that period, those responsible for the services too often provided clinical care that was suboptimal and led to significant harm, failed to listen to the families involved, and acted in ways which made the experience of families unacceptably and distressingly poor.
Had care been given to the nationally recognised standards, the outcome could have been different in 97, or 48%, of the 202 cases assessed by the Panel, and the outcome could have been different in 45 of the 65 baby deaths, or 69% of these cases. The Panel has not been able to detect any discernible improvement in outcomes or suboptimal care, as evidenced by the cases assessed over the period from 2009 to 2020.
1.6 We have no doubt that these numbers are minimum estimates of the frequency of harm over the period. We made no attempt to review other records or to contact families who did not volunteer themselves. It was our judgement that we had enough evidence based on the existing 202 cases to identify the problems and their causes, and we did not wish to delay publication of our findings.
1.12 We have found that the Trust wrongly took comfort from the fact that the great majority of births in East Kent ended with no damage to either mother or baby.
1.13 This failure reflects badly, not only on practice within East Kent maternity services, but on how statistics are used to manage maternity services across the country as a whole. We believe that it should be possible for individual trusts to monitor and assess whether they have a problem; that it should be possible for the NHS regionally and nationally to identify trusts whose safety performance makes them outliers; and that it should be possible for the regulators to
differentiate the services provided more quickly and reliably.
1.14 More immediately, the Trust should acknowledge the full extent and nature of the problems which have endured over the period. It has not yet done this in full. We have found that its failure to do so explains why the action that has been taken has not been sustained and has not had the impact needed.
1.19 We have found that the origins of the harm we have identified and set out in this Report lie in failures of teamworking, professionalism, compassion and listening.
1.21 We found gross failures of teamworking across the Trust’s maternity services. There has been a series of problems between the midwives, obstetricians, paediatricians and other professionals involved in maternity and neonatal services in East Kent. Some staff have acted as if they were responsible for separate fiefdoms, cultivating a culture of tribalism. There have also been problems within obstetrics and within midwifery, with factionalism, lack of mutual trust,
and disregard for other points of view.
1.110 In keeping with the familiar pattern of downplaying problems and seeking to avoid external scrutiny, the Trust classified baby Harry’s death as “expected” on the basis that he was admitted to the neonatal unit at WHH with severe HIE, and therefore death was not an unexpected outcome. For that reason, the Trust initially refused to refer baby Harry’s death to the coroner for investigation. There were errors in the data sent to the national audit, Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK).
1.111 Baby Harry’s family faced great difficulty in finding out what had gone wrong, although they were sure that something had, and they began to distrust any information they received from the Trust. The weeks, months and years that followed baby Harry’s death involved sustained efforts by his family to seek understanding and truth about what had happened during his delivery. Their efforts included referring the case to HSIB and to the CQC for investigation and pressing to have a full inquest into the circumstances of his death.
1.112 This pattern of behaviour by the Trust, clearly evident in this case, recurred in many others that we examined. It included denying that anything had gone amiss, minimising adverse features, finding reasons to treat deaths and other catastrophic outcomes as expected, and omitting key details in accounts given to families as well as to official bodies. Although we did not find evidence that there was a conscious conspiracy, the effect of these behaviours was to cover up the truth.
1.113 Even had none of the previous failings been known – and they were – baby Harry’s death should surely have been a catalyst for immediate change. In fact, it required public remonstration by a coroner over two years later, precipitated by the persistence, diligence and courage of baby Harry’s family, to reveal an organisation that did not accept its own failings, considered itself above scrutiny or accountability, and consistently rejected the opportunity to learn when things went wrong.
1.115 From the outset, HSIB experienced difficulties in its dealings with the Trust, including problems obtaining information, staff attendance at interviews, and support for the process from the Trust’s senior leadership team. HSIB found this to contrast sharply with the response of other trusts in the region, which generally welcomed the opportunity to have “fresh eyes” on any problems. The East Kent Trust, on the other hand, challenged HSIB’s right to carry out investigations and its credentials to act as what the Trust saw as another regulator.
1.116 HSIB’s concerns increased over the course of 2018, particularly over failures to escalate clinical concerns, unsupported junior obstetric staff, the use and supervision of locum doctors, management of reduced fetal movement, neonatal resuscitation, and fetal monitoring and its interpretation. In light of its “grave concerns”, HSIB sought a meeting with the Trust’s senior leadership team, which took place in June 2019.
1.117 The accounts of that meeting that we heard from more than one source left us shocked, given the extent of the problems at the Trust that by then had been evident for almost ten years. The HSIB team was not made welcome but was left waiting in a corridor for an extended period. Senior executives greeted them in an “incredibly aggressive” manner, saying “I don’t know why you are here” and telling HSIB that its recommendations were “not needed”. The tone of the meeting was one of defensiveness and aggression, and there was a “heated discussion” about a maternal death.
1.121 We have found that repeated problems were systemic, particularly reflecting problems of attitude, behaviour and teamworking, and they reflect a persistent failure to look and learn. They concerned both hospitals and continued throughout the period we have investigated. They included poor professional behaviour among clinicians, particularly a failure to work as a cohesive team with a common purpose.
1.122 Each of these problems has been visible to the senior management of the Trust. In these circumstances, while it is right that this report should be clear about those systemic issues and how they have been evident through the organisation, we have concluded that accountability lies with the successive Trust Boards and the successive Chief Executives and Chairs. They had the information that there were serious failings, and they were in a position to act; but they ignored the warning signs and strenuously challenged repeated attempts to point out problems. This encouraged the belief that all was well, or at least near enough to be acceptable. They were wrong.
1.133 In essence, it is clear that in East Kent the Trust too often treated the concerns expressed by families as “noise” when they were in fact an accurate signal of real problems. One example is how the family of baby Harry Richford was treated, particularly when they sought answers to legitimate questions. But that is not the only such example. The accounts we have heard from families show persuasively that the Trust’s mindset was too often to be defensive and to
minimise problems; and that this mindset was itself a barrier to learning.
1.139 We have found a worrying recurring tendency among midwives and doctors to disregard the views of women and other family members. In fact, in a significant number of cases, the Panel has found compelling evidence that women and their partners were simply not listened to when they expressed concern about their treatment in the days and hours leading up to the birth of their babies, when they questioned their care, and when they challenged the decisions that were made. Too often, their well-founded concerns were dismissed or ignored altogether.
1.140 A particular area of concern was the telephone advice given to mothers to stay at home if they were not adjudged to be in established labour. It is foolhardy to disregard the woman’s voice, especially if she has experience of previous labour, and we saw evidence of distressing births before the mother’s arrival in the maternity unit as a result. But it is dangerous when the caller has also reported other problems such as altered movements by the baby, and we saw examples of babies lost as a consequence of such advice.
1.69
Another similarity is that both families have wanted their experience to be considered in order that the services be improved. The fact that it took the experience of Sarah and Tom Richford, seven years after the experience of Lucy and David Bennington, to bring East Kent maternity services into national focus suggests that the issues are deep and entrenched, and that the Trust has not been ready to look for signs of problems.
1.77 The Panel heard that the CCGs were “met with anger and defensiveness by the Trust, always, no matter whether it was a financial challenge or clinical challenge” – “you took a deep breath to have the conversations before you picked up the phone or you met with them”.
1.89 The Head of Midwifery decided, with HR, that some senior midwives who were repeatedly identified as central to the issues should be relocated or suspended pending further action. A collective letter of grievance with 49 signatories was subsequently submitted via the RCM, alleging failures of process in the review. It is notable that this letter admitted that the unit was “dysfunctional”.
1.90 We heard that, as a result, the Trust withdrew support from the review process and from the Head of Midwifery. Consequently, she resigned from her post in August 2015. She requested advice from the RCM on whistleblowing about the culture of bullying and intimidation prevalent in the unit and was advised against disclosure in the interests of patient safety because of the risk this posed to her future career prospects. It is notable that the RCM was already aware of the dysfunctional behaviours at the Trust.
1.91 The Panel heard of no further efforts to address the bullying behaviour, which, we heard, persisted. This was another significant missed opportunity.
4.138 One clinician told the Panel that they did not recognise some of the issues that were highlighted in either the CQC or the RCOG report. A senior midwife remembered the RCOG report being dismissed by a senior consultant obstetrician as a “load of rubbish”. The midwife commented to the Panel that Trust obstetricians did not like the light being shone on them in that way.
4.315 We heard that HSIB had difficulties with its day-to-day operational relationship with the Trust. These included issues such as information requests, staff attending for interview, staff giving their consent to attend for interview and difficulty in getting support with this from the Trust’s senior leadership team. The Panel heard that the HSIB team had a “very difficult reception from East Kent”, despite its efforts to build good relationships: “engaging with the governance team at East Kent would be difficult”. This contrasted with other trusts. Consequently, HSIB investigations were delayed because the relationship wasn’t good from the outset. However, an HSIB investigator said that, when they were able to engage with more junior staff, these staff were open and honest.
4.316 In 2018, engagement between HSIB and the Trust included preliminary recommendations from an HSIB review of ten ongoing HSIB investigations, visits to the Trust in October and November (including a presentation on HSIB’s work) and a round-table meeting with the Trust in December. The meeting in December identified emerging patient safety themes, including neonatal resuscitation, documentation processes and escalation during care; these were followed up in a letter to the Trust. However, it was clear that the Trust “did not want to engage with HSIB at all”.
4.317 The Panel heard that obstetricians did not attend any meetings with HSIB, although they were invited to do so. One HSIB investigator’s assessment was that the obstetricians didn’t want to engage in such discussions, rather than that they were excluded from doing so:
"In 2018, obstetricians didn’t see incidents – especially those involving midwifery – as anything to do with them."
4.324 As a reflection of the level of concern within HSIB about the performance of East Kent maternity services, a letter was issued to the Trust CEO in August 2019 by Sandy Lewis, Associate Director of the Maternity Programme at HSIB. This was considered a highly unusual step. The letter stated:
"Given the gravity of the concerns raised and the lack of response to the issues raised, I consider that there may be a serious continuing risk to safety within your Trust."
4.331 An HSIB investigator told the Panel that there was a strong culture of “pushing things under the carpet” and not listening to staff who raised concerns. We were also told of a striking disconnect between staff on the ground and the management team.
4.335 The Panel heard that the Trust’s 72 hour reports were “very poor”; they didn’t go into detail and HSIB provided training to help improve the quality. However, the reports remained poor. Initially, the Trust would not share these reports with HSIB. The Trust challenged why HSIB would need them and said that “they aren’t there to help you with your investigation”.
4.336 HSIB still saw cases where women presented with symptoms that appeared to be an infection but were sent home without being seen by a senior person, only to return in a more serious state. Professor Walker commented that “it is about proper assessment, risk assessment, escalation, and things like that … but to be fair the numbers [became] less than they were”.
4.337 The most prominent HSIB themes in 2018/19 were guidance, escalation, fetal monitoring, documentation and birth environments. The themes in 2019/20 were guidance, escalation, fetal monitoring, staffing and general clinical oversight.
4.340 Ms Sutcliffe told the Panel that the NMC received some referrals around maternity incidents at East Kent: “[I]t was very much on an individual basis, and our analysis shows that quite a lot of these referrals were coming through from families.” In the case of baby Harry Richford, the family referral included four midwives and the NMC opened cases on a further three midwives as a consequence of that family referral. No referral was made by the Trust.
4.361 NHSE was alerted by HSIB about the lack of senior engagement in 2019. In response, an intelligence-sharing call was convened with NHS Resolution (NHSR), the CQC, HSIB and the CCGs, which identified the following issues:
- NHSR raised concerns about the Trust being an outlier for claims.
- The Richford family were concerned that the Trust wasn’t meeting the requirements of NHSR and CNST. A whistle-blower had also raised concerns about adherence to CNST requirements.
- The CQC expressed frustration about the lack of information coming back to them.
- HSIB raised concerns about the number of cases being higher than the national average and about the “scattergun” nature of the response from the Trust, particularly in relation to the Harry Richford case. There was no evidence of lessons being learned and there were issues with the way in which the Trust was managing the relationship with the family.
- NHSE had concerns about reports from HSIB.
- The CCGs had concerns about how difficult it was to get information from the Trust, CTG monitoring, the multiple action plans, changes in Heads of Midwifery, and the Board not being sufficiently focused on maternity services. The lack of Board to ward oversight and the lack of escalation to the Trust Quality and Safety Committee and the Board were continuous themes.
4.146 The Panel heard from Nick Hulme, a Trust Governor, that, even as recently as 2020, at Council of Governors meetings it was regularly highlighted that it was “not fair” that East Kent scored lower down the lists of trusts, given the large size of the Trust and that it had “a lot of comorbidities”. Mr Hulme told the Panel that governors were told to “ignore the press” because they had “an agenda”. Mr Hulme also told the Panel that he had been actively dissuaded from speaking to the Panel by a member of the Board, who told him that he “would not add value”.
4.29 The biggest obstacle to implementing change – in particular the improvement plans in response to the 2014 CQC report and the Royal College of Obstetricians and Gynaecologists (RCOG) report in 2016 (see Chapter 1) – was the lack of staff engagement with the process. The Trust was described as reactive and not “terribly forward-looking” in changing the culture around staff engagement.
5.112 A meeting took place a few days later, on 14 March, between the family and the Trust to discuss the RCA’s findings. This meeting appears to have been challenging for all involved (it was described to the Investigation by one member of staff as “a complete car crash” for the Trust). The meeting room furniture was disorganised, requiring the family to rearrange it when they arrived; one of the consultants arrived ten minutes late; and another consultant had to be called to attend from Ashford. There were disagreements among the clinicians within the meeting, and inaccuracies and inconsistencies in the report emerged throughout the meeting (for example, whether there were problems relating to CTGs within the unit). The family’s impression was that they were treated poorly by the Trust, spoken to like children, and dismissed when they raised concerns.
5.113 A critical issue for the family was the Trust’s failure to refer Harry’s death to the coroner, a concern which was raised by Tom Richford shortly after Harry died. The RCA report addresses this question as follows:
"The coroner was not informed as the cause of death was known to be hypoxia and death occurred later than 24 hours from birth. There was a clear sentinel event coupled with difficulty in resuscitation, this fits clearly with HIE. Again coupled with the MRI findings and the MRI report, there was no uncertainty with regards to causation and the death certificate."
It should be clear that this is a wholly inadequate reason to evade referral to the coroner, when both mother and baby had been healthy at the onset of labour.
5.117 In June and July 2018, the Trust commissioned independent medical reports into the care received by Sarah Richford and the neonatal resuscitation of Harry Richford. Both reports were critical of the treatment provided by the Trust, yet neither report was shared with NHSE or NHSI at the time. Derek Richford, one of Harry’s grandfathers, made a complaint to NHSI in December 2018, raising concerns that the Trust was not learning from incidents. The response
from the Medical Director was that lessons had been learned by the Trust, and that on receipt
5.119 The Richford family also contacted the CQC regarding Harry’s case. The CQC’s initial assessment was that the issues related to one doctor who had made a mistake, but there were no systemic issues to investigate. Again through the persistence of the Richford family, the issue was escalated to the CQC’s Chief Inspector of Hospitals, and in October 2020 the CQC announced that it was prosecuting the Trust in connection with the care provided to Harry and Sarah Richford. In March 2021, the Trust pleaded guilty to an offence of failing to provide safe care and treatment, resulting in avoidable harm to Harry and Sarah. The Trust was fined £761,170.
5.134 On 4 December 2018, Derek Richford submitted a complaint to the NHSI National Medical Director stating that the Trust was not learning from incidents. NHSI contacted the Trust’s Medical Director, who reported that, following the RCA, two independent reviews had been undertaken, by an obstetrician from the Maidstone and Tunbridge Wells Trust and by a paediatrician from the Dartford and Gravesham Trust. They stated that lessons had been learned by the Trust and changes had been made to practice. (This was wholly untrue - both reports and both authors were called to Harry's inquest to give evidence about the failings they had written of). The HSIB report was due in January 2019 and would contain an assessment, conclusion and recommendations regarding the standard of care received by Sarah and Harry Richford. Following this, the Trust would put in place an action plan. The Trust reported to NHSI that they had told the CCG of this. However, the CCG reported that they only became aware when they declined closure of the RCA due to a number of queries.
There are very many more comments in the full report. However, the litany shown above, demonstrates that the scandal in East Kent HAD to be exposed.