Kentish Gazette Canterbury & District
GUILTY PLEA
Hospitals in court over baby’s death
East Kent Hospitals has admitted criminal charges relating to the “wholly avoidable” death of a baby in an unprecedented court case.
Harry Richford died following a traumatic birth involving a catalogue of failures by medics at the QEQM Hospital in Margate in November 2017. On Monday, at Folkestone Magistrates’ Court, the hospitals trust pleaded guilty to failing to provide safe care and treatment to Harry and his mother Sarah Richford. His family welcomed the plea as it will avoid the awful details of his birth having to be replayed in public once more. “This is the first case of a criminal prosecution of an NHS trust for poor clinical care by the Care Quality Commission and demonstrates the severity of issues that were discovered,” they said. “Although this case is about Sarah and Harry, it also led to numerous contacts from other families who found themselves in a similar position at the trust.”
They said they believe almost 200 such families have now come forward to the Kirkup inquiry, which is looking into the standard of care provided by the maternity and neonatal service at EKH since 2009. Last year, a coroner ruled that Harry was failed by the hospital following a three-week inquest which found his death was “wholly avoidable”.
The inquest heard evidence detailing a series of worrying incidents in the lead-up to his birth and distressing details of the panic-stricken medical team who delivered him. Little Harry’s heart rate dropped frequently throughout the long labour and there was a disagreement between staff over whether to administer the drug Syntocinon to progress labour. Questions were also raised over whether Mrs Richford was suffering from the dangerous condition uterine hyperstimulation, which can impact the baby’s heart rate.
The exhausted mother was rushed into theatre, where medics attempted to deliver Harry with forceps before an emergency caesarean was performed by an inexperienced locum. When he was born “silent and floppy” an anaesthetist dealing with Sarah had to step in after 28 minutes after a locum registrar failed to get him to breathe.
Had Harry been successfully resuscitated within 10 to 15 minutes of being delivered he would have survived and not suffered irreversible brain damage. Once intubated, he had to be transferred to the neonatal intensive care unit at the William Harvey Hospital in Ashford. He was so unwell his parents were not able to hold him until the morning of the day he died from hypoxia, on November 9, 2017, aged just a week old,
leaving his parents, from Birchington, devastated.
The CQC started a formal criminal investigation in October 2019 and the trust was charged with exposing Harry and his mother to significant risk of avoidable harm.
It was brought under Regulation 12 of the Health and Social Care Act, and is the first prosecution of its kind to relate directly to clinical care. Harry’s death led to numerous other cases of maternity incidents emerging.
Last year, the hospital trust’s board admitted the number of potentially avoidable baby deaths could be as many as 15 in seven years.
As well as Dr Bill Kirkup’s independent inquiry, the Healthcare Safety Investigations Branch (HSIB) is currently examining three individual maternity cases. Following Harry’s inquest in January of 2020, an expert team was put into the trust to deal with the issues raised by the coroner, the CQC and HSIB. Since that time, neonatal deaths have dropped by 55% and still births by 20% compared to the seven-year average. The Richford family said: “This proves that with the right level of focus, leadership and attention, babies’ lives can be saved.
“Harry’s life and our sacrifice has made a significant difference here in east Kent and it must be maintained.” Speaking after the hearing, 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. “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.” The trust will be sentenced on June 18, with a hefty fine the expected punishment.