Case study of maternity care failings at East Kent Hospitals NHS Trust

Following the long-anticipated publication of Dr Kirkup’s investigation into the maternity care provided at East Kent Hospitals NHS Trust, medical negligence specialist Mark Stafford-White shares the experience of his client who received care at Queen Elizabeth The Queen Mother Hospital.

In 2015, Ms C was 32 weeks pregnant with her second child when she noticed that she had felt a reduction in foetal movements over the previous 24 hours. After discussions with her partner, they decided to visit the QEQM Hospital in Margate to seek advice and reassurance.

Ms C was admitted to the maternity ward, and at 07:25 a CTG trace was commenced to monitor her baby’s heartbeat. By 09:00, it had been noted by the maternity doctor that there was a lack of accelerations in the heart rate, and the CTG trace was recorded as ‘suspicious’, which ought to have prompted enhanced monitoring to ensure her baby was not in any danger. An urgent ultrasound was subsequently ordered and was reported as being normal. In actual fact, the ultrasound had shown the blood flow in the Middle Cerebral Artery to be less than the lower centile, meaning the supply of blood and oxygen to the baby was already jeopardised.

By 11:40, the CTG trace was showing irregular tightenings and was again reported as suspicious. At this stage, an emergency C-section was required, but no further action was taken.

At 16:45, there is an entry within the records to show that hospital staff had contacted a number of neonatal units across the South East of England to locate an emergency neonatal intensive care unit cot, but there were said to be none available. The CTG trace remained suspicious.

By 21:00 that evening, there was no change in Ms C’s presentation, and the CTG trace monitoring the baby’s heart rate was still recorded as suspicious. The decision was made to stop the CTG trace so that Ms C could go for a walk around the hospital to stretch her legs and get something to eat.

At 23:55, the CTG trace was recommenced. At 00:30, it was noted again that the CTG trace was not showing any accelerations in the heart rate, but Ms C was advised to get some sleep and use the call bell if her baby’s heart rate decreased any further.

Approximately 15 minutes later, Ms C had started to drift off to sleep when she realised from the sounds of the monitor that the heart rate was falling rapidly. She pressed the alarm and was quickly seen by a junior doctor and a midwife. The decision was finally made to proceed to an emergency caesarean section.

An hour later, Ms C’s baby was delivered and needed seven minutes of resuscitation from the neonatal team before she was able to breathe independently. Her baby was transferred immediately to the special care baby unit and later received an emergency transfer to the William Harvey Hospital in Ashford.

Baby C was born with severe hypoxic injuries caused by a lack of oxygen in the period immediately prior to her birth. Although it was considered possible that she may have suffered from minor injuries, even with timely delivery, the failure to proceed with an emergency caesarean earlier that day meant that her condition had deteriorated significantly by the time that she was born.

In her short lifetime, Baby C was diagnosed with HIE Grade 2, aspiration pneumonia, metabolic acidosis, thrombocytopenia, jaundice, hypophosphatemia, hypokalaemia, neonatal hypocalcaemia, neonatal hypomagnesaemia, hypotension, and gastro-oesophageal reflux. She spent eight weeks in hospital before being allowed to spend her final days at home with her family. Baby C tragically passed away at just 65 days old.

Despite all of the failings noted in the Kirkup review and all of the recorded missed opportunities for intervention and reform, Baby C’s case will not feature in the findings as her family were not contacted to participate. The much-quoted statement that “the outcome could have been different in 45 of the 65 baby deaths” would, therefore, appear to be an underestimation of the true scale of the traumatic events at East Kent Hospitals and the devastating impact that this has had on the families.

A medical negligence specialist as Ashtons comments: “the Kirkup report has revealed a complete institutional failure of care at East Kent Hospitals over the past decade. These failings are ingrained in the patient experience, and the report speaks of staff being dismissive of patient concerns or being too afraid to challenge incorrect decisions made by senior colleagues. Although it is far too late to change the tragic outcomes for the families already affected, urgent action and reform is required to address the concerns identified within the report and prevent these harrowing events from repeating themselves in the future.”