Only two out of 23 recommendations from a royal college review into a trust’s troubled maternity services can be shown to be fully implemented, a new investigation has revealed.
A learning and review committee, set up by East Kent Hospitals University Foundation Trust, found that 11 more of the recommendations from a 2016 review by the Royal College of Obstetricians and Gynaecologists (RCOG) were “partially” implemented.
But it said there was either no evidence the remaining 10 had been delivered, or there was evidence they were not implemented.
The original RCOG review looked at a number of cases where babies had died as well as broader issues within the maternity service at the trust.
The committee was set up after an inquest into the death of Harry Richford, who died a week after his birth in 2017 at the trust’s Queen Elizabeth, the Queen Mother, Hospital in Thanet. Many of the issues which came to light at his inquest echoed those from the RCOG report.
Committee chair Des Holden, medical director of Kent Surrey Sussex Academic Health Science Network, highlighted the difficulties in tracking evidence and action plans during a time when the trust had significant changes in leadership. But he said the committee felt cases where evidence could not be found or the standard of evidence gave concern, the recommendations could not be said to be met.
Derek Richford, Harry’s grandfather, said on behalf of the family: “We are saddened and shocked to find that over four years after the RCOG found fundamental systemic failings and made 23 recommendations, only two have been completed. It is not good enough for them to now say ‘leadership has changed’. The main board must take responsibility and be held to account.”
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Source: HSJ, 13 July 2020