It's difficult to imagine how much more suffering can be inflicted onto families coping with the devastation of losing a baby.
But that appears to be happening with the publication of yet another damning report into substandard and inhumane maternity services at another NHS hospital trust.
East Kent NHS Hospital Trust now joins the unthinkable series of failing care that includes Nottingham University Hospitals Trust and Shrewsbury and Telford NHS Trust.
The latest independent investigation, led by obstetric specialist Dr Bill Kirkup (who also chaired the 2013 Morecambe Bay Investigation), found that up to 45 babies might have survived with better care at The Queen Elizabeth the Queen Mother Hospital (QEQM) in Margate and the William Harvey Hospital in Ashford, both under the trust's responsibility between 2009 and 2020.
Dr Kirkup uncovered a 'clear pattern' of 'sub-optimal' care that led to significant harm, that families were ignored, with the trust appearing intent of 'covering up the scale and systemic nature' of its problems. The report also states that harm was not restricted to physical damage but that there was repeated lack of kindness and compassion following injuries and deaths.
Dr Kirkup's team also found some maternity staff acted 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 sub-optimal care provided in both hospitals," the report said.
One also has to wonder what use the comments from former health secretary Jeremy Hunt – himself responsible for the NHS from 2012 to 2018 - that the scandal is 'simply unthinkable', plus the belated promise from Health minister Dr Caroline Johnson that the Government is committed to 'preventing future tragedies'.
I speak for every one of the medical negligence team who deal with birth injury cases and stillbirth claims in highlighting the hope of all our clients suffering the tragedy of losing a baby that lessons learnt from their case might improve maternity care to prevent other families going through what they have.
To hear yet again that nothing appears to have been learnt from each baby's death is beyond unbearable.
Read more about our birth injury claims.
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