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The Kirkup Review, which was published this morning following an investigation into maternity care at east Kent hospitals, makes for harrowing reading.

The inquiry looked at more than 200 cases affecting families at the East Kent Hospitals University NHS Foundation Trust dating back to 2009. These are some of their stories.

'They were blaming me for her death'

Helen Gittos had gone through a difficult labour with her first child, and so was determined to avoid the same the second time around.

However, when she was admitted to the Queen Elizabeth the Queen Mother (QEQM) Hospital in Margate to give birth to daughter Harriet, she said that things had already started to go wrong.

"Harriet was a healthy, full-term and uncomplicated pregnancy, but because of my difficult first labour I wanted to discuss my second," she explained.

"For months, I was treated with complete disinterest, the first chance I had to truly talk about my concerns was around a month before I was due."

Unfortunately for Ms Gittos and her husband Andy Hudson, their already-poor experience would turn into a tragedy upon admission to the QEQM in August 2014.

"When we asked questions during my labour, it was treated as though we were non-compliant and we got absolutely no answers," she said.

"My progress was very slow and it was hard for me to be sure what happened at the hospital because my contractions were so strong – but I know we were not seen by the most senior doctor on the ward.

"By the time we were finally given a c-section, it was too late and Harriet was too poorly."

The young tot was transferred to St George's Hospital in London for intensive care, where she tragically died a week Unfortunately, her parents' ordeal was not yet over.

"For me, the way the trust responded afterwards was shocking," Ms Gittos said.

"It was clear from the outset from [the trust's] notes that they were blaming me for her death – even in the notes taken during labour saying I was non-compliant.

"There was a serious incident review report that I saw, and it had undergone 12 revisions. At the start, it was graded as serious, with severe harm and neonatal death. By the time it was finally submitted, her death was listed as 'unexpected admission to neonatal unit'."

The couple had another child the following year, at a different trust. Their eight-year wait for answers since the tragedy could well culminate today.

"Blaming the mother is a very effective way of shutting them up, and it took me a long time to ask for an independent review – which I did in 2018," explained Ms Gittos.

"When I asked the trust, they refused to review it as they had no obligation to do so, and if they had done so, it could have opened up for a legal case, despite us not having any interest in purusing one.

"One of the worst things is none of this [investigating] would be happening if we, and other families like the Richfords hadn’t gone to the press and there had been such a public outcry; and that is just terrible."

'They tried to pass off my five-day-old baby's death as stillbirth'

"The similarities between Helen's ordeal and mine are clear to see," says Kelli Rudolph.

The professor of Classics and Philosophy had known Helen Gittos previously, having met at the University of Kent in Canterbury where the latter also taught for a number of years.

Tragically, the pair were to have another bond – in shared grief at the loss of a baby.

Just over two years after the death of Harriet Gittos at the QEQM, Kelli was rushed into the William Harvey Hospital after her midwife became concerned over the welfare of her daughter Celandine.

"I had a healthy pregnancy, but my community midwife in Canterbury was worried about her heartbeat," she explained.

"They sat me down in the labour ward for half an hour, before I was told I was taking up space and needed to leave.

"When I asked the doctor for an ultrasound, I got a lecture about stillbirth and intrauterine death. I then had to sit for three hours waiting for the scan, and then hours more again before I saw the doctor – all with absolutely no monitoring."

Just two days later, Kelli went into labour in her garden at home. Immediately, she noticed that something was wrong.

"I saw dark meconium – the baby's first stool – which can be extremely dangerous to a newborn during labour," she said.

"The baby's heartbeat dropped from 120 beats per minute to 90, and I was rushed into hospital again."

Expecting to go in for an emergency c-section – a common practice for troublesome or dangerous births – Kelli was instead taken to the labour ward.

There, after more than an hour's labour, Celandine was pulled pale and unresponsive from her mother, and rushed into the resuscitation unit.

She was brought back to life after 10 minutes, but tragically died five days later in the arms of her father, Dustan Lowe.

However, like Helen and Andy, the couples' ordeal was far from over.

"When we got her death report, they gave her cause of death as stillborn, despite the fact that she was alive for five days," explained Kelli.

"We asked them for it to be referred to the coroner, but they said no and that there was no need for an inquest.

"We were lead to believe there was a serious incident report, and after four months of being fobbed off we finally met with doctors and midwives to raise our concerns.We were told everything we said would be fed into the investigation... but it was finished that very day.

"Worse, they sought to blame me for her death, said I was refusing treatments and induction of labour, which was completely false."

The couple would continue to work with the trust, including talking to new doctors and nurses to train them almost a year on, when Kelli discovered she was pregnant with twins.

"We left then, and I gave birth to them with the Medway trust as it was apparent to both of us that absolutely nothing had changed," she said.

'I kept asking why I couldn't hear my baby'

In many ways the spark that lit the fire, the "wholly preventable" death of Harry Richford at the QEQM in 2017 prompted a probe that has grown into what we now know as the Kirkup report.

The young boy's mother, Sarah, was admitted to hospital and underwent a long labour and chaotic delivery by emergency caesarean, performed by an inexperienced locum.

When young Harry was eventually delivered it took medics almost half an hour to resuscitate him. During this time, a midwife would later to go on to describe “panic” in the room, while a staff nurse said the scene was “chaotic”.

Sarah, forced to relive the moment in a subsequent inquest, said that she could hear people shouting during the operation.

"Dr (Christos) Spyruolis said 'cut her more here' and shouted to a midwife to 'push Harry's head back up'. It felt like nobody was in control," she explained.

"No-one was more afraid than me. I was helpless, exhausted and distressed, laying on an operating table, listening to a room of panicking people - people I was relying on to deliver my baby.

"No-one was saying what was going on.

"Once Harry was born, I kept asking why I couldn't hear my baby. I wanted to know if it was a boy or girl as we hadn't found out.

"A midwife came over and said he was a really good weight and I knew that wasn't good, that she was just trying to be kind."

Distressed, in pain and needing more surgery, Sarah was put under general anaesthetic before she had a chance to see Harry.

He tragically died just seven days later in intensive care, with the trust recording his death as "expected".

It was not until Sarah and her husband Tom repeatedly pushed for an inquest that the true failings came to light, with coroner Christopher Sutton-Mattocks ruling his death was "wholly avoidable", and "contributed to by neglect” and “gross failure”.

A criminal investigation – the first of its kind – resulted in the trust being fined £733,000 last year.

Speaking to reporters after the inquest, Sarah and Tom accused the trust of "trying to avoid outside scrutiny," and failing to learn from similar cases.

"This system is specifically designed to aid national learning of infant deaths," they added.

"Accidents happen every day but failing to learn from them appears to have become part of the culture of this NHS trust."

'You go through all the joy... then it all gets taken away'

Archie Powell was born happy and healthy alongside his twin sister Evalene, to overjoyed parents Dawn and Kevin.

The couple, who had three other children – all girls – welcomed the twins to the world at the QEQM in February 2019.

However, Harry, who had been born a healthy 6lb 5oz, fell ill just hours after birth, when he started making grunting noises – a symptom associated with respiratory distress which can be caused by group B streptococcus, a bacteria which can make babies seriously ill unless treated quickly.

But despite concerns raised by midwives just after 7am, he was not medically assessed by a paediatrician until 9.25am, at which point he had stopped grunting and so was simply kept under observation.

However, he started grunting again at 10.50am and had become hyperthermic – and yet another a delay occurred, this time in admitting him to the special care baby unit (SCBU), where he eventually arrived at 12.45pm with "significant respiratory difficulty".

There, the registrar recognised Archie had sepsis and needed antibiotics, but it wasn't until three hours later - at 3.50pm - they were administered.

He was later transferred to London where medics found he had contracted the bacterial infection and had sepsis.

A scan showed the tot had little brain activity and his heartbroken parents had to make the decision to switch off his life-support machine just four days after his birth.

A subsequent inquest found that Archie would have survived if he had been given antibiotics before midday.

Mrs Powell said: “It was a shock to find out we were having twins in the first place, then you go through all the joy and you have all these plans in your mind, but then it all gets taken away.”

'Nothing can bring him back to us, we can only hope that true lessons will be learned'

Like so many before her, first-time mum Rachel Higgs had enjoyed a drama-free, uncomplicated pregnancy until she began to go into labour.

However, when she first arrived at the QEQM presenting with nausea and vomiting, she was not even allowed to be admitted on the basis that she was not in active labour.

When she returned, fully dilated, she and her partner Andrew Batten were again turned away, this time due to the hospital being on 'divert' because of a lack of beds.

Then the Broadstairs couple were advised to drive the 38 miles to the William Harvey Hospital in Ashford, but chose to make the shorter journey home rather than face an hour-long journey on the verge of giving birth.

Community midwives were sent to their home and the exhausted mum-to-be spent five hours trying to push Archie out during a prolonged and complicated labour.

While mothers normally give birth two hours after being fully dilated, it was not until five hours after this point that an ambulance was called by the midwives, having realised the severity of the situation.

By the time she reached the QEQM once more, Archie had been born in a poor state. He breathed independently for a brief moment, but died less than half an hour later.

A subsequent inquest found that basic checks that should have been – but were not – carried out could have given information that would have saved Archie's life.

It found that neglect contributed to his death, with coroner Sonia Hayes finding that there were multiple "obvious" missed opportunities to save his life.

This included the fact that the young mum should never have been sent home in the first place.

Speaking after the inquest in June this year, Ms Higgs and Mr Batten said: ""It seems incredible to us that so many basic mistakes were made by so many people

"Archie would be two and a half years old now. We think about him and miss him everyday and always will.

"Nothing can bring him back to us, we can only hope that true lessons will be learned from this case and lasting changes made to ensure other families do not suffer such tragedies in the future."

'I knew something wasn't quite right, it was my gut instinct'

Shelley Russell was eagerly anticipating the arrival of her daughter Tallulah-Rai, so much so that she and partner Nicholas Edwards had already decorated the nursery and picked out all of her clothes in sizes up to her first birthday.

They had always wanted a child together – having each had two from previous relationships – but had never expected it to happen after finding out Shelley had a blocked fallopian tube.

However, at 36-weeks pregnant Shelley – who was in the high-risk category having had a miscarriage before – noticed that Tallulah-Rai was moving less than normal, and went to Buckland hospital in Dover for a heart-rate scan, or cardiotocography (CTG).

She was then told there was "nothing to worry about", she went home.

Two days later, she found out her daughter had died in the womb. A post-mortem later found she died of oxygen deficiency.

Shelley said: "When we found out she had died I felt broken.

"All of our hopes and dreams had come to an end. Our whole world came crashing down on top of us."

Worse was to come, as the horrified couple later found midwifery notes which said the baby's heart rate reading was "poor quality".

A damning doctors letter from an expert who reviewed the medical records questioned why was she sent home.

The letter said: “The question to me was, on review of the notes, why was she sent home on January 23 when she presented to the maternity day unit at Buckland Hospital with reduced foetal movement?

“I have had a look at the tracing of the CTG. She had one on January 11 and January 23 and I have compared both tracings.

“Certainly, there is some difference in both tracings. The tracing on January 11 is essentially normal, however the tracing on January 23 had a comment made on it which said ‘poor quality trace’ after she presented with reduced foetal movements.

“The question to me was, why was she not kept on tracing a bit longer or an ultrasound arranged. That is what I would have expected and I cannot really answer why this was not done.”

Shelley added: "I knew I should not have been sent home. I knew something wasn’t quite right. It was my gut instinct.

"It’s devastating. I feel as though my baby’s death could have been prevented.

"The grief is unbelievable. I spend every day wishing to have our baby girl here with us."

An internal investigation by the trust found that the CTG "should have been continued for longer and an ultrasound arranged."

There are countless other cases looked at under the Kirkup Review, which was published this morning.

These include but are not limited to:

Reid Andrew Shaw (November 2019), whose mum Kirsty Stead was told to "take paracetamol and go to sleep" after reporting severe pain and her son moving excessively.

When she called later the same day to say she had not felt him move for hours, she was brought in – only to be told that he had died. She alleged that if she had been asked to come into hospital when she first called at 1.10am her son would be alive. An investigation was started by the trust but the conclusion is currently unknown.

Freddie White (April 2016), who was found to be suffering from twin-to-twin transfusion syndrome, a serious condition where one of two twin foetuses is getting more of the blood supply from the placenta than the other.

His mum Nicola Grimmett did not see a consultant for two days after this was discovered, and it was a further day before she had a caesarean section.

The hospital were not able to revive Freddie, and Nicola believes he would have survived had he been delivered earlier.

East Kent Hospitals said: "We accept that Freddie's death might have been avoided had we acted differently and we wholeheartedly apologise for this."

Hallie-Rae Leek (April 2017), who died four days after birth. During labour, a midwife struggled to find her heart rate and by the time Hallie-Rae was born, she was in a poor condition. It took 22 minutes to resuscitate her, but irreparable damage had been done.

The trust accepted the death was preventable and apologised.

One way or another, their stories will be told. For many parents, the knowledge that so many share in their pain is both a comfort and a further heartbreak.

Kelli Rudolph said: "It is a special kind of pain to think that you are unique, which is what they tried to make us think; and then we learn that it's the opposite, that we’re one couple of many and we probably walk past people every day in Canterbury that have suffered every day.

"When you think about it, we are the fifth largest ecomony in the world, and women and children are dying here like we are the most remote country on the planet.

"It is absolutely shocking. It’s not because there’s a lack of care or resource, it’s that decisions are being made by authorities in the trust that are simply poor and negligence."

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