The death of a baby who lived just 27 minutes after being delivered at QEQM Hospital in 2019 was contributed to by neglect, an inquest has concluded.
Archie Batten was born on Sunday, September 1, 2019. The Inquest into his death ended today (June 10) in Maidstone. Her Majesty’s Assistant Coroner for North Kent Sonia Hayes concluded neglect, missed opportunities and gross failures led to baby Archie’s death and he would have survived without complications or neurological injury if his mum had been admitted to hospital earlier.
Failures
First time mum Rachel Higgs was denied admission to QEQM’s maternity department and instead told to drive to William Harvey Hospital in Ashford.
The QEQM unit was ‘diverting’ after a decision was taken to close due to a lack of bed spaces.
Rachel had tried to gain admission to the maternity ward that morning but was directed to the Maternity Day Care Centre where she was examined twice over a two hour period but refused admission on the basis that she was not in active labour.
She and partner Andrew Batten were assured a room would be kept available for her when she re-presented at any time.
But before they left the hospital, at 2.35pm a decision was taken to close the QEQM Maternity Unit, leaving patients needing their services having to ‘divert’ to the William Harvey Hospital in Ashford.
After a show and intense contractions, Rachel phoned the QEQM shortly before 5pm only to then be told that the unit was shut and that she should attend the William Harvey.
This was not a practicable option as the couple did not believe Rachel could make the journey to the William Harvey, and feared her having to give birth on the side of the road.
They were told that a community midwife would be sent out to see her.
Over the next 5 hours, Rachel was seen at home by a succession of four midwives but they did not appreciate that she had reached the second stage of labour and the baby needed to be delivered and that her membranes were ruptured at a very late stage with a failure to keep proper records of the foetal heart rate.
An ambulance was called at just gone 10pm and Rachel was taken to QEQM. Maternity services there had become operational again a couple of hours earlier but the couple say there had been no communication between the hospital and the midwives.
By the time Rachel got to the QEQM Archie was delivered but was born in a very poor condition.
He managed to breathe independently for a short period but this was not maintained. Resuscitation attempts were ended and he died at just 27 minutes of age.
The Trust admitted the ‘sub standard care’ in a letter sent to the Fairweather solicitors, acting for the family, in July 2020.
Inquest findings
Adopting a narrative conclusion, Coroner Hayes, who heard evidence in the case over more than 2 weeks, found that East Kent Hospitals Trust did not have proper systems in place for home births while on divert at the time in breach of Article 2;
Rachel should not have been sent home at 2:30pm. Nor should she have been told, at that point, that she could come back at any time, with a room kept for her, when the Maternity Unit was just about to go onto divert.
Instead the Trust eventually sent no fewer than 4 midwives to her home just 5 minutes away whilst all the while keeping the Maternity Unit on divert due to a lack of midwives.
All 4 midwives failed to comply with basic requirements of midwifery, individually and cumulatively, over a 5 hour period from the first attendance until 10pm when Rachel and Archie were finally given an emergency transfer to the hospital.
There was a failure by the Trust / Midwifery Unit, on the one part, and the community midwives, on the other part, to communicate the fact that the Unit was taken off divert at 8:30pm at which point Archie should have been transferred into hospital and delivered. Had this been done then he would have been born without complications or neurological injury.
Even when the midwives finally realised the urgency to the situation and arranged the emergency transfer there were further failings in communication whereby Rachel and Archie arrived in the hospital with neither the obstetricians nor the neonatologists having been properly alerted.
By the time Archie was eventually born at 10.42pm it was too late for him. The failures cost him his life. Had he been transferred to hospital he could have been saved and delivered without any neurological complications as late as 10.15pm.
After his birth, and during his resuscitation, the Trust’s record keeping was inaccurate and Archie was not stillborn, as the Trust and the midwives tried to argue, but lived with clear signs of life (heartbeats) up until 27 minutes of age.
‘Systemic failings’
Nick Fairweather, the family’s solicitor, who represented them at the Inquest pro bono, together with barrister Richard Baker of 7 Bedford Row, said: “The family had to wait over 2 ½ years for the Inquest and are appalled at how they have been treated by the Trust and their legal representatives.
“This was exemplified by the Trust attempting to persuade the Coroner not to hear the case on the basis that Archie was stillborn, waiting until just before the hearing before making that application. Whilst this application was given short shrift it added enormously to the family’s distress and anxiety and indeed their distrust of this Trust.
“Any renewed apologies for what happened cannot now be accepted. The systemic failings of the Trust have a depressingly familiar ring to them seen across our case load of QEQM cases It is important that the Coroner has recognised, however, that even when operating in a dysfunctional Department and in a sub optimal clinical setting it was still the professional responsibility of the individual midwives to provide a due and proper level of care to Archie and Rachel. This they manifestly failed to do.”
‘Justice for Archie’
Speaking following the conclusion in a statement released through their solicitors parents Rachel and Andrew said: “Listening to all the evidence in the case has been hard. It seems incredible to us that so many basic mistakes were made by so many people on the day of Archie’s birth and death.
“ We do feel, [however], that we have got justice for Archie today and thank the Coroner for her expertise and the thoroughness of her investigation. We also thank our legal team, who representing us free of charge at the Inquest, without which we would not, on our own, have been able to stand up to the Trust’s expensive lawyers and ensure that Archie’s case was properly considered.
“Archie would be 2 ½ years old now. We think about him and miss him every day and always will. Nothing can bring him back to us. We can only hope that true lessons will be learned from his case and lasting changes made to ensure that other families do not suffer such tragedies in the future.”
Tracey Fletcher, Chief Executive of East Kent Hospitals, said: “On behalf of the Trust, I apologise unreservedly to Archie’s parents and family for Archie’s death.
“We fully accept the Coroner’s findings and conclusion today and we are deeply sorry for the failings in the care provided to Archie and his family in September 2019.
“We have made – and continue to make – changes and improvements to the quality and safety of our maternity service. Since Archie’s death, we have made changes to how we care for women and babies during a homebirth; and to how we provide the service when the hospital maternity units are busy.
“The lessons from Archie’s death, and the findings of the independent investigation into our maternity service being led by Dr Bill Kirkup, will be built into our continued improvement, to ensure we provide high-quality maternity care for families in East Kent.”
Maternity service concerns
Concerns were raised about the safety of maternity services at the Trust at the inquest into the death of baby Harry Richford, who died at Queen Elizabeth The Queen Mother Hospital in 2017. A number of families then came forward over the ‘preventable’ deaths of their babies.
The troubled maternity service has been subject to a report by the Health and Safety Investigation Branch (HSIB) which found recurrent patient safety risks at the Trust maternity sites at QEQM Margate and William Harvey Hospital and is subject to a review commissioned by NHS England and NHS Improvement into the maternity and neonatal services.
The investigation is being led by Dr Bill Kirkup and is expected to cover the period since 2009.
Fairweathers Solicitors represent 18 families who have suffered still births, neonatal deaths or other injuries arising at the QEQM Hospital Margate, or other hospitals operated by the East Kent Trust. Most of the cases are being considered by the Kirkup Enquiry into maternity services in East Kent.
