Morecambe Bay

Up to 45 babies may have survived if they had received better care at East Kent NHS Hospitals Trust, a damning independent review has found.

It found a " clear pattern" of " sub-optimal" care that led to significant harm and families were not listened to.

The medical experts reviewed an 11-year period from 2009 at two hospitals in Margate and Ashford.

The Trust , which previously said it was " determined to learn any lessons" .

The Independent review, which was chaired by Dr Bill Kirkup CBE, added The Trust had given The Appearance of " covering up The scale and systemic nature" of its problems.

And it found that there was " no evidence to convince us that this cycle has ended".

Investigators said The Trust wrongly took comfort from The fact most births at East Kent ended with No Damage to mother or baby.

And they found harm was not just restricted to physical damage, and there was repeated lack of kindness and compassion even in The Aftermath of injuries and deaths.

Dr Kirkup's team also found " gross failures" of team-working across The Trust 's maternity services, with some staff acting As If they were responsible for " separate fiefdoms, cultivating a culture of tribalism".

" The dysfunctional working we have found between and within professional groups has been fundamental to The suboptimal care provided in both hospitals, " The Report said.

A series of failings emerged during, who died Seven Days after being born in 2017.

The hearing in January 2020 found Harry's death at The Queen Elizabeth The Queen Mother Hospital (QEQM) in Margate was " wholly avoidable".

The Trust was fined £733,000 for failing to provide safe care and treatment for him and His Mother Sarah Richford.

The Richfords have long campaigned for answers after saying their concerns were repeatedly brushed aside by hospital managers.

The Trust has apologised for Harry's death, which it initially said was " expected". However it was not The First incident of its Kind .

Following mistakes during his delivery at The William Harvey Hospital in Ashford.

Afterwards, The Trust was put into special measures by The Care Quality Commission, which rated its maternity services as " inadequate".

Directives for improvement were made, but The Trust .

Harry Richford's family claim their baby might not have died if The Trust had learned from The death of Harry Halligan, and have spent years demanding systemic change at East Kent's maternity units.

Other Parents said they felt they were blamed by The Trust after they lost their babies.

The review examined The circumstances of maternity deaths at both The QEQM and The William Harvey .

In an email to staff last month, trust chief executive Tracey Fletcher said The Report would make " harrowing" reading and have a " profound" impact on families and colleagues.

Dr Kirkup, who met with families affected during The probe, has led several reviews, including chairing The Investigation of.

Speaking ahead of The Report 's publication, Dr Kirkup told BBC Radio 4 's Today programme: " When I reported on Morecambe Bay maternity services in 2015, I did not imagine for one moment that I would be back in seven years' time talking about a rather similar set of circumstances and that there would have been another two large, high-profile maternity failures as well on top of that.

" This cannot Go On . We have to address this in a different way.

" We can't simply respond to each one As If it's a one-off, As If this is The Last time this will happen. We have to do things differently. "

Nadine Dorries , The former minister for patient safety, that The review at East Kent would be held.

The Report was originally intended to be published last month, but was delayed Following The death of Queen Elizabeth Ii .