East Kent hospitals: Parents call for inquiry after coroner rules baby died of neglect

Grieving parents of a baby boy who died as a result of neglect at a scandal-hit maternity unit say the hospital tried to hide failings in their son’s care by not reporting the death to the coroner or properly investigating.

Staff also wrongly claimed Harry Richford’s death had been expected in a series of official documents that included incorrect information about his birth.

Now his parents, Tom and Sarah Richford, have called for an inquiry into poor care at the East Kent University Hospitals Trust after The Independent learned there have been dozens of deaths and more than 130 babies suffering brain damage in recent years.

Harry’s father said: “I’d like this trust to be put under the spotlight, because there are a number of other families who have suffered too.

“After this trust has had that public inquiry, I think maternity in this country needs to have a massive overhaul. We are far below other countries in Europe, in terms of maternity safety, which is absolutely crazy. Given the fact that we are one of the most developed countries in Europe, I don’t understand why we are. It should be that our maternity care is one of the safest. And if it isn’t, we need to be asking questions.”

A coroner ruled baby Harry, who was born at the Queen Elizabeth The Queen Mother Hospital in Margate in November 2017, died as a result of neglect following catastrophic errors by panicking doctors and midwives.

After a traumatic caesarean delivery performed by an inexperienced locum doctor who had not been properly assessed by the trust and a delay of more than 25 minutes in helping him to breathe, Harry suffered a severe lack of oxygen and brain damage. He died a week later.

Assistant coroner Christopher Sutton-Mattocks ruled Harry’s death was “contributed to by neglect” and “wholly avoidable”, although he stopped short of concluding it amounted to unlawful killing.

Delivering his conclusion in Maidstone’s County Hall on Friday, he said Harry’s parents were grieving for a “much-desired and much-loved baby” who “should not have died”. The coroner added: “Mr and Mrs Richford were failed by the hospital, but more importantly, Harry was failed.”

Harry’s family have hit out at the hospital after learning bosses had been warned about many of the factors in Harry’s death by an expert review of maternity services by the Royal College of Obstetricians and Gynaecologists (RCOG) in 2015.

Sarah Richford said: “Reading the RCOG report makes me angry because if you read that report, it literally, word for word, says exactly what happened to Harry.”

Tom Richford said the family’s battle for answers had revealed the trust was unwilling to be transparent and open. He said: “They found out about this in February 2016. And yet by November 2017, they had not mitigated those risks. That is something which I find is unacceptable.”

The RCOG report was unearthed by Harry’s grandfather Derek Richford, 58, who spent hours reading NHS reports and tracing the poor care in the maternity unit over several years.

He told The Independent: “When you see your children in such pain, it gives you huge motivation.

“I certainly felt this was a David versus Goliath battle. We’ve had to jump through hoops and loops all the way down the line. We’ve had no help with this.

“I believe that the trust did everything, and I mean everything possible, to avoid Harry’s case, going to the coroner’s court.”

After Harry died, the trust refused to refer the case to the coroner, claiming his death was expected because they knew the cause. aDerek Richford eventually reported the death himself in March 2018.

Tom Richford said: “Harry was full term, there was absolutely nothing wrong with him, it was a textbook pregnancy. And then he dies after seven days, that is not expected in any way, shape or form. So we asked a number of times for the coroner be informed and they said again and again the coroner was not needed.”

Despite internally investigating what happened as a serious incident, the trust completed an official child death notification form claiming Harry’s death was expected.

The trust also failed to keep the placenta and did not share key blood test results with the pathologist carrying out his post mortem examination. This proved Harry’s lack of oxygen happened because of the delays in his resuscitation.

An internal investigation into Harry’s death was carried out by the lead consultant for the maternity unit, and the neonatal consultant in charge of Harry’s care, who signed his death certificate, arranged the post mortem and child death notification form.

This report has now been withdrawn by the trust after a number of details were criticised by external experts.

Harry’s father said: “The RCA investigation said it was systemic failings but at the inquest the trust is blaming individuals. They change the message depending on the audience. It looks to me like the trust has tried to avoid external scrutiny, we don’t know how many times this has happened before. It just feels like there’s a culture of not wanting to report to the coroner.

“All I have ever wanted since is the truth. I need the truth to be able to successfully move on and remember Harry positively. I need to feel Harry did not die in vain and the mistakes which happened have been corrected and will not happen again.”

His wife Sarah said it had been hard to hear the trust admit it had let them and their son down, adding: “It does make me very angry that Harry died unnecessarily and that we don’t have our baby. He should be here, he should be alive and it’s the hospital’s fault that he’s not.

“Two years later, we are only now just getting the answers we feel we deserve.”

Paul Stevens, the medical director of East Kent University Hospitals, said the trust fully accepted the coroner’s findings and was “deeply sorry” for “the devastating loss of baby Harry”.

He added: “We fully accept that Harry’s care fell below the standard that we want to offer every mother giving birth in our hospitals.

“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.”

The trust said it had made a number of changes to its maternity services since Harry’s death, including the way it monitors babies’ heart rates during labour, recruitment and supervision of locum doctors, and staff training.

The Care Quality Commission (CQC) this week conducted an unannounced inspection of the trust’s maternity services – which were rated “requires improvement” in 2018. The CQC said it would publish its findings as soon as possible following the three-day inspection, which was due to conclude on Friday.

Ted Baker, the chief inspector for hospitals, said: “The 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.”

If you think you might have been affected by poor care at the East Kent University Hospitals the trust has set up a helpline on 01233 651900