East Kent Hospitals apologises as stillbirths review reveals eight babies ‘might have survived’ with better care

Eight babies might have survived if they had received different maternity care at hospitals in east Kent, an independent review has found.

The review examined 11 stillbirths involving babies born at 34 weeks or later between June 2025 and March 2026.

It found care deficiencies were “likely” to have affected the outcome for four babies, while issues in a further four cases “may have” made a difference.

The East Kent Hospitals University NHS Foundation Trust (EKH), which runs the William Harvey Hospital in Ashford and the QEQM in Margate, has apologised to families for the failings.

The findings have been published in board papers for a meeting being held by the Trust tomorrow (Thursday).

The independent review identified what it described as “recurrent and systemic weaknesses” rather than isolated failings.

These included the management of high-risk pregnancies, maternity triage, fetal surveillance, escalation of concerns and organisational learning.

The review found particular problems with recognising and managing conditions including hypertension and pre-eclampsia, responding to fetal growth concerns and dealing with cumulative clinical risk factors.

It also raised concerns over the consistency of maternity triage, including assessment, escalation, documentation and timely senior clinical decision-making.

In four of the cases, the review team said failures to act on the overall clinical picture and arrange delivery in a timely way may have contributed to the deaths.

The review found 20 major modifiable factors, 35 minor modifiable factors and 21 wider learning issues across the 11 cases.

These included concerns over telephone triage, face-to-face triage, triage documentation, ultrasound scanning, planned timing of birth and care following the diagnosis of an intrauterine death.

There were also concerns about the use of interpreters.

In one case involving a mother who did not speak English, a family member was used to interpret at the booking appointment and there was no further reference in the records to an interpreter being used during subsequent antenatal appointments.

The review team said the lack of interpreting services was likely to have been an important factor in the outcome.

It also found two cases where scan reports contained contradictory information which was important to the subsequent management of the pregnancy.

In both cases, the report said the anomalies were not identified by staff producing or reviewing the scans.

The review described these as “very serious quality assurance failures”, adding that intrauterine death occurred within five days in both cases.

The review team made 16 recommendations for improvements to maternity care.

They include improving access to interpreters, reviewing pathways for women who miss appointments or fail to make contact, strengthening the management of hypertension and improving the quality assurance of ultrasound scanning.

The Trust said the independent review was commissioned after its own monitoring identified an increase in stillbirths.

Board papers say the number of stillbirths had risen above the Trust's threshold from September 2025, prompting the review to be commissioned in October that year.

But the concerns did not end with the 11 cases examined.

The Trust's papers say there were a further four term stillbirths between April and July 2026 and another six stillbirths in August.

Those additional cases are now being independently reviewed by the same external team, with the findings due to be reported to the board.

The Trust also received feedback following a diagnostic visit by the NHS England Maternity and Neonatal Improvement Support Team earlier this month.

The visit highlighted the need for greater clinical ownership and accountability, a sustainable medical staffing model for maternity triage, stronger governance, improved sonography oversight and further work on fetal monitoring.

It also called for maternity triage data to be reported directly to the Trust board and for clearer processes for resolving differences in clinical opinion.

The Trust has produced an action plan covering the recommendations and says it will continue to monitor their implementation.

In his written report to the board, Dr Des Holden, acting chief executive of East Kent Hospitals, wrote: “On behalf of the board, and personally, I am very sorry and apologise to the women and families, and their communities, where failings in our care are at the heart of these devastating outcomes.”

Following the publication of the papers, he added: “This review is clear that sadly, we have failed families. We are truly sorry.

“We asked for this review after increased safety monitoring within our maternity service, implemented after Dr Bill Kirkup’s investigation, enabled us to quickly identify an increase in the number of stillbirths at our Trust.

“We investigated each stillbirth and commissioned this independent review of 11 stillbirths to identify any common themes and learning.

“We are implementing the review’s recommendations in full, including improving continuity of care for women with high-risk pregnancies, maternity triage, enhancing staff training and increasing the amount of translated information and access to interpreters. We are working with the national Maternity and Neonatal Intensive Support Team to ensure our services meet the standards women and families deserve.”

The findings come three years after the publication of the Kirkup review into maternity services at East Kent Hospitals, which found that 45 babies may have survived with better care.