A scandal-hit NHS trust has today pleaded guilty to failing to provide safe care and treatment following the death of a baby boy, in the first prosecution of its kind.
Harry Richford died seven days after his emergency delivery at the Queen Elizabeth the Queen Mother (QEQM) Hospital in Margate.
An inquest later found that his death in November 2017 was ‘wholly avoidable’.
At Folkestone Magistrates’ Court in Kent today, the East Kent Hospitals University NHS Foundation Trust admitted failing to provide safe care and treatment to Harry and his mother, Sarah.
Harry’s parents Tom and Sarah Richford today said they had ‘some sort of justice’ after spending years fighting for change.
Mrs Richford said after the hearing: ‘We’ve got some level of justice that means that although Harry’s life was short, hopefully it’s made a difference and that other babies won’t die.’
‘If somebody had done this before Harry was born he may be alive today.’
Sarah and Tom Richford with their son Harry, who died seven days after he was born in November 2017
Harry’s father Tom Richford (with wife Sarah) pictured outside court in January last year
What were the failings at East Kent NHS?
The trust at the centre of a scandal over baby deaths failed to deliver Harry Richford on time, 92 minutes after an expert advised he should be.
Harry died at just seven days old after being delivered by C-section on November 2 last year.
The QEQM also gave Mrs Richford a drug to speed up labour, which hyper-stimulated the infant.
Archie Batten died on September 1 shortly after being born. His mother had called QEQM to say she was in labour.
But she was told the maternity unit was closed and to drive herself to the trust’s other hospital, Ashford’s William Harvey, 38 miles away.
Four midwives went to her home after the journey was deemed not feasible but they struggled to deliver the baby.
The mother was transferred by ambulance to QEQM, where her son died. His inquest in scheduled for March.
Archie Powell died at four days old on February 14 after medics treated the twin for a bowel problem.
They failed to spot he had a common infection despite him showing all its symptoms and the delay in treatment sparked severe brain damage.
Tallulah-Rai Edwards was stillborn on January 28. Her mother had become anxious in the 36th week of pregnancy due to her baby’s slowed movement and went to hospital.
Despite struggling to get a good heart-rate reading on the cardiotocography (CTG) machine, midwives sent her home. The baby was found to have died two days later when her mother returned to the hospital.
Hallie-Rae Leek died aged four days old on April 7 2017. A midwife had struggled to find a heart-rate and she was born in a poor condition.
She was resuscitated after 22 minutes but the damage was irreparable.
There were two stillbirths at the trust in 2016, in March and June. In the first case, the unit failed to recognise that an infant was small given the stage of development. They did not act on suspicious CTG readings and failed to deliver the baby promptly.
In the second case, the trust missed risk factors and failed to properly monitor a CTG and a baby girl died.
Last year, a 2016 review into the trust by the Royal College of Obstetricians and Gynaecologists emerged which claimed three or four consultants ‘consistently’ failed to attend the maternity wards out of hours on weekends and evenings.
The report, uncovered by Harry’s grandfather, Derek Richford, was seen by The Independent.
At an inquest into Harry’s death last year, Coroner Christopher Sutton-Mattocks said Harry should have been delivered within 30 minutes.
But instead he was delivered after some 92 minutes.
The coroner also found that an inexperienced doctor was in charge of the birth, and there was a failure to request support from a consultant earlier.
Harry’s mother, a teacher, was considered to be ‘low-risk’ during her pregnancy.
She had been taken to theatre for an emergency Caesarean section on November 2, 2017.
After arriving at hospital, Mrs Richford was given a drug to speed up labour over a period of 10 hours – a decision which was criticised by the coroner, because it hyper-stimulated Harry.
She was rushed to theatre after he began to show signs of distress, where medics tried to deliver with forceps before performing an emergency section.
Locum registrar Dr Christos Spyroulis, described by the coroner as ‘inexperienced’, delivered Harry at 3.32am.
It emerged in the inquest that there was no record of the doctor being assessed, and he had said that he was not asked about his level of experience.
The coroner said staff nurse Laura Guest, who had been called to help with the emergency delivery, had described the scene as ‘chaotic’, adding she ‘didn’t feel it was being strongly led’.
Resuscitation began after Harry was born ‘silent and floppy’ and not moving.
Mr Sutton-Mattocks said the situation must have been ‘terrifying’ for Mrs Richford, as there were between 20 and 25 people in the theatre.
The inquest heard that if Harry had been resuscitated within ten to 15 minutes of birth, he would not have suffered the irreversible brain damage that killed him.
Anaesthetist Dr Dhir Gurung stepped in after 28 minutes to intubate Harry, an action praised by the coroner, who said it gave the family seven days to spend with the baby.
Harry was then transferred to the intensive neonatal unit at William Harvey hospital, where he died on November 9.
Mr Richford said the East Kent Hospitals NHS Trust knew there was an ‘extreme risk to pregnant women and neonatals in their care’ at the time of Harry’s birth.
The trust pleaded guilty to failing to provide safe care and treatment under the Health and Social Care Act 2008 (Regulated Activities) Regulations.
Harry’s mother said the guilty plea in court shows the care she and Harry received was sub-standard, adding they now have ‘some sort of justice for what happened’.
Speaking ahead of the hearing, Harry’s father Tomsaid: ‘At every hurdle it did seem that the hospital were trying to avoid scrutiny, they didn’t want to lose out on their reputation.
‘So we kept having to fight and fight and fight and eventually we’ve now got the inquests, and the inquiries and the investigations that really mean that change should hopefully be more systemic and sustainable.’
The maternity unit of the Queen Elizabeth the Queen Mother (QEQM) Hospital in Margate
The Healthcare Safety Investigation Branch (HSIB) has been investigating East Kent Hospitals University NHS Foundation Trust since July 2018 following a series of baby deaths.
An independent report published last April by the Department of Health and Social Care outlined 24 maternity investigations undertaken since July 2018, including the deaths of three babies and two mothers.
Dr Bill Kirkup, who led the investigation into serious maternity failings at University Hospitals of Morecambe Bay NHS Foundation Trust, is leading an independent review into East Kent Hospitals’ maternity services.
Mr Richford said it feels there has now been a ‘change in tide’ at the trust that they hope will continue.
He added: ‘They’re now beginning to admit their errors and mistakes and hopefully that will continue.
‘The whole time you admit and own your mistakes you’ll hopefully learn from them, but the whole time you’re brushing them under the carpet then the same mistakes will happen again and again and again.’
Mrs Richford said she hopes the eventual recommendations from the Kirkup review will be listened to.
East Kent Hospitals chief executive Susan Acott said: ‘We are deeply sorry that we failed Harry, Sarah and the Richford family and apologise unreservedly for our failures in their care.
‘We are determined to learn when things go wrong. Our midwives, our doctors and every member of our staff constantly strive to give good care every day. We have already made significant changes following Harry’s death and we will continue to do everything we can to learn from this tragedy.
‘We are working closely with national maternity experts to make sure we are doing everything we can to make rapid and sustainable improvements.
‘We have welcomed the independent investigation into maternity services in east Kent and we are doing everything in our power to assist and support the investigation.’