East Kent Hospitals Maternity: Babies Are Still Dying — Four Years After Kirkup, Known Failures Remain

Babies have died. East Kent had already been warned. It had already been investigated. It had already been told what was wrong. It had already produced the plans, the committees, the pathways, the training, the governance structures and the assurances.

And still the same failures keep returning.

At some point, “systemic weakness” stops being an explanation and starts becoming a shield.

Because a system did not fail these women and babies by itself. People did. People made the decisions. People failed to act. People failed to supervise. People failed to make sure previous warnings were turned into safe practice. And people at senior level were paid — and paid well — to make sure that, after the Reading The Signals report, this could not happen again.

Yet nearly four years later, an independent review of 11 stillbirths found that deficiencies in care were likely to have made a difference to the outcome in four cases and may have made a difference in another four.

That is not an “embedding issue”.

That is not a “governance challenge”.

That is not a “journey of improvement”.

It is failure. Absolute failure

The Trust can wrap it in whatever language it likes — “systemic weaknesses”, “governance concerns”, “partial assurance”, “learning not embedded” — but those phrases risk becoming a cloak of invisibility, allowing individual responsibility to disappear into the machinery of the organisation.

Nobody appears to have failed.

The “system” failed.

The “process” failed.

The “governance” failed.

NONSENSE. Absolute NONSENSE

Somebody was responsible for the process. Somebody was responsible for the governance. Somebody was responsible for supervision. Somebody was responsible for ensuring known dangers were fixed. Somebody was responsible for checking whether previous “improvements” were actually working.

The Trust itself admits several of the latest failings had been identified before and that improvements had still not been consistently embedded in frontline care.

That shouldn’t make people furious. It should make them livid

East Kent did not lack warnings.

It lacked effective delivery and accountability.

Take hypertension and pre-eclampsia. Reviewers found concerns in four cases. In one, diagnostic criteria for pre-eclampsia were met but the woman was not correctly reclassified. The reviewers described what they found as serious care failings.

East Kent already knew this was a problem.

Its own response says hypertension and pre-eclampsia had featured in previous patient-safety work. Training, guidance and surveillance had already been undertaken.

Yet the failures remained.

So what, exactly, had all that “improvement” achieved?

Triage is worse.

Two women reporting bleeding by telephone were advised that they did not need to attend, contrary to the BSOTS maternity triage process. In another case, reviewers believed the telephone interaction was likely to discourage attendance. The woman came to hospital three days later with reduced fetal movements.

Her baby had died.

Once women got through the door, reviewers found incorrect triage categorisation, delays, absent medical reviews and documentation so poor that sometimes they could not establish whether women had been assessed within the required times.

The second page of the BSOTS assessment card was not used in 13 of 16 relevant attendances.

The reviewers called it “a systemic failure in training, supervision and governance of the triage process.”

Again, that word: systemic.

But who was responsible for the training?

Who was responsible for the supervision?

Who was responsible for the governance?

“Systemic” cannot be allowed to mean “nobody”.

The ultrasound findings are equally damning. Problems with scan interpretation or management appeared in seven of the eleven cases. In two, reports contained contradictory clinically important information which was not detected by those producing them or by clinicians who later reviewed them.

Both babies died within five days.

The reviewers described these as “very serious quality assurance failures” and identified potential missed opportunities to prevent death.

Four cases also involved missed opportunities for earlier birth.

The reviewers were not talking about some obscure technicality buried in a 300-page guideline. They said there had been a failure to bring together the whole clinical picture — blood pressure, diabetes, fetal growth, scan findings and other warning signs.

They called it a failure of clinical synthesis and raised clinical competency concerns.

One case should be engraved on the memory of everyone running this service.

A woman with poorly controlled type 2 diabetes had delivery between 37 and 38+6 weeks discussed. She missed an appointment.

The reviewers say the team then “lost oversight” of her.

No induction was arranged.

She later returned with extremely high blood pressure.

Her baby had died.

The review called the gap between the plan and what happened “a governance failure.”

Even after babies had died, the failures did not stop.

One woman attending at 10pm was told to return the next day for secondary confirmation of her baby’s death. Another had no documented midwifery care for five hours after an intrauterine death was confirmed, followed by delayed recognition and treatment of suspected sepsis. Another woman was sent home despite anhydramnios and infection risk. Reviewers called that a serious care failure.

And perhaps the most damning part of all is that East Kent was already reviewing these deaths.

Its own Perinatal Mortality Review Tool processes were identifying many of the same problems. What the organisation was failing to do reliably was join those warnings together, recognise recurring patterns and force through effective change.

The warnings existed.

The organisation failed to convert them into dependable safer care.

Then NHS England arrived again in September.

Staff reportedly said improvements were not consistently sustained without external oversight. NHS England identified further problems around clinical accountability, triage staffing, governance, perinatal learning, sonography, fetal monitoring and escalation.

That is an extraordinary admission.

If improvements only survive while outsiders are watching, they were never properly embedded.

Meanwhile the deaths continued.

After the review was commissioned, four further term stillbirths occurred between April and July 2026 and another three in August. Those cases are being externally reviewed too. Across the 12 months to August there were 29 stillbirths, including 15 at term.

The Trust itself offers only partial assurance. Its Quality and Safety Committee rated maternity assurance LIMITED, while triage remained a live patient-safety risk.

No woman entering maternity care should be placed in harm’s way because an NHS Trust has spent years failing to turn known lessons into routine safe practice.

East Kent has had the warnings.

It has had the recommendations.

It has had the support.

It has had the external oversight.

It has had nearly four years.

What it no longer has is a credible excuse.

And there comes a point when accountability has to mean something more than another action plan, another review and another carefully worded assurance paper.

“Systemic weaknesses” do not exist in some abstract vacuum. They are created, tolerated, missed and left uncorrected by people. People are responsible for clinical leadership. People are responsible for governance. People are responsible for supervision. People are responsible for making sure the same failures do not happen again.

If, after nearly four years, those charged with fixing East Kent maternity still cannot make basic safety improvements stick, then some of them should no longer be in those jobs.

Where responsibility for repeated failure is established, dismissal should be on the table.

East Kent does not need another mountain of paper explaining why lessons have not been embedded.

It needs consequences.

Because reports do not fail women and babies.

People do.

The Shepway Vox Team

Dissent is NOT a Crime