A coroner has ruled that the death of seven day old Harry Richford at Margate’s QEQM Hospital in 2017 was avoidable.
The inquest had heard of the “panic” after Harry was born by emergency Caesarean section during which his heartbeat kept dropping. Harry died seven days after his delivery from a condition caused by a lack of oxygen. An independent report said he might have survived had there not been a delay in resuscitation at his birth that caused irreversible brain damage.
Today (January 24) Coroner Christopher Sutton-Mattocks agreed with that conclusion and said Harry and his parents had been ‘failed.’
There was also criticism of the hospital trust which had said Harry’s death was expected, resulting in his parents, Tom and Sarah Richford, from Birchington, having to fight for an inquest.
‘Harry’s death must not be in vain’
The couple were supported by North Thanet MP Sir Roger Gale, who has commended them for their ‘courage and quiet dignity.’
The MP has also criticised the East Kent Hospital Trust for initially being ‘obstructive’ and said that Harry’s death must not be in vain.
He said: “I would like to commend the courage and quiet dignity with which my young constituents, Tom and Sarah Richford, have conducted themselves since the death of their infant son, Harry, and throughout the process since.
“I have been engaged in this sad case since the family approached me following their loss and it is immediately apparent that their only concern has been to seek to ensure that no other young family has to suffer as they have done. To lose a child is terrible. To know that that loss could and should have been prevented adds immeasurably to the pain.
“I would like to express my thanks to the barristers and solicitors who have given their services tirelessly and without charge to seek to ensure that my constituents have been fully and properly represented.
“Lawyers are frequently criticised but through Advocate (The Bar Pro Bono Unit) the Richford family has received superb legal support. They have not just `gone the extra mile`: they have, I am advised, run a marathon to secure the truth.
“There have been many failings, both medical and administrative, in this case. The Coroner has determined that Harry`s death was avoidable and I believe that in the early stages the hospital authorities were obstructive in their efforts to prevent the facts from being established. What should have been a straightforward process therefore contributed to the family`s ordeal.
“Many changes have already been made as a result of this case and more must follow. I have discussed the matter personally with the Secretary of State and Matt Hancock has assured me that there must be full transparency in further enquiries that will have to be undertaken and that every last lesson possible must be learned to prevent any repetition of this kind of tragedy and to restore full confidence in the maternity services within the East Kent hospitals trust.
“We owe that to the Richford family, to future mothers using the service and to a dedicated team of staff within maternity at the QEQM who wish to provide the best possible facilities and attention to those, mothers and babies, in their care. Harry Richford`s death cannot be allowed to have been in vain.”
Review of maternity services
Significant concerns about maternity services at the trust were raised as the inquest into Harry’s death came to a close and it emerged a damning report had been written after the trust asked the Royal College of Obstetricians and Gynaecologists to review the service in 2015.
An investigation carried out by the BBC claims seven baby deaths at the WHH and QEQM units, including Harry’s, since 2016 could have been preventable.
According to further research by The Independent between 2014-2018 there were 68 baby deaths at the trust for children aged under 28 days old and of those, 54 died within their first 7 days. There were 143 stillbirths and 138 babies suffered brain damage after being starved of oxygen during birth.
A Trust spokesperson said: “We recognise that we have not always provided the right standard of care for every woman and baby in our hospitals and we wholeheartedly apologise to families for whom we could have done things differently.
“We are reviewing our service with some of England’s leading maternity experts to make sure we are doing everything we can to make rapid improvements to maternity care in east Kent.”
‘We are so sorry and apologise wholeheartedly’
Dr Paul Stevens, Medical Director for East Kent Hospitals, said today: “We are so sorry and apologise wholeheartedly for the devastating loss of baby Harry. We fully accept that Harry’s care fell below the standard that we want to offer every mother giving birth in our hospitals.
“Mr and Mrs Richford’s expectation in November 2017 was that they would welcome a healthy baby into their family and we are deeply sorry that we failed in our role to help them do that.
“We recognise the mistakes in both Harry’s delivery and subsequent resuscitation and acknowledge that there are things that we could and should have done differently. With great sadness we accept that we failed Harry and his family, and apologise unreservedly.
“We are also truly sorry that Harry’s family was not given the support and answers they needed. We deeply regret the extra pain that our delays have caused them.
“We cannot imagine the pain the Richford family has endured. The lessons we can learn from their continued commitment to understanding the circumstances of Harry’s death will help families in the future.
“We fully accept the Coroner’s findings and recommendations. We are determined to learn when things go wrong and have already made significant changes to our service following Harry’s death. Our midwives, doctors and every member of our staff constantly strive to give good care and seek to improve every day.
“We are working closely with national maternity experts to make sure we are doing everything we can to make rapid and sustainable improvements. We are committed to learning the lessons from Harry’s death.”
CQC investigation
The Care Quality Commission has confirmed it is investigating the situation. Under Regulation 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 a prosecution could be brought.
Ted Baker, Chief Inspector for hospitals at the Care Quality Commission (CQC) said: “CQC’s 2016 inspection rated maternity services at East Kent NHS Foundation Trust as Requires Improvement, identifying that staffing levels were impacting on the quality of patient care. That rating remained unchanged at our 2018 inspection, during which it was noted that the department had changed its approach to foetal monitoring training after concerns were identified.
“The trust remains subject to close monitoring and further inspections. We conducted an unannounced inspection of the Trust’s maternity services on 22 and 23 January 2020 and we will publish the findings of this inspection as soon as we are able to
“CQC is aware the inquest into the death of Harry Richford at East Kent Hospitals University NHS Foundation Trust is due to complete on Friday 24 January and await the findings of this inquest.
“CQC’s investigation is ongoing and no decision has been taken at this stage on whether we will prosecute the trust for a failure to provide safe care or treatment resulting in avoidable harm or a significant risk of avoidable harm.”
Reassurance
The Trust says women who are currently expecting a baby can contact their named midwife if they would like reassurance about their current care.
Women who have been under the care of East Kent Hospitals’ maternity service in the past and have concerns about their care can contact 01233 651900.
