Poor baby Harry didn’t need to die
Coroner’s verdict as boy’s parents demand inquiry into ‘wholly avoidable’ tragedy at blunder hospital
THE death of a newborn baby was yesterday found to be ‘wholly avoidable’ as a coroner accused medical staff of neglect.
Harry Richford suffered a 92minute delay in his ‘chaotic’ delivery by an ‘inexperienced’ locum doctor after a consultant failed to arrive in time.
The baby died seven days after being born by Caesarean section in November 2017 despite his mother’s ‘textbook’ pregnancy.
A 2016 Royal College of Obstetricians and Gynaecologists report had found the hospital was ‘vulnerable’ because of the ‘reluctance/ of three or four on-call consultants to attend when requested’.
Harry’s parents fought for two years for answers before a coroner yesterday ruled after a threeweek inquest in Maidstone, Kent, that the death was caused by a catalogue of errors which amounted to ‘neglect’ and had been ‘wholly avoidable’.
Last night the family, who are suing the NHS trust, welcomed the verdict and said it finally allowed Harry to ‘rest in peace’. They called for a public inquiry into maternity services at the trust which runs Queen Elizabeth The Queen Mother Hospital in Margate.
Sarah and Tom Richford – both 31-year- old teachers – had been excited about becoming first-time
but were instead left mourning. Coroner Christopher Sutton-Mattocks said: ‘They are grieving for a child they believe should not have died. I agree with them. Mr and Mrs Richford were failed by the hospital, but more importantly Harry was failed.’
He also criticised the hospital for not informing the coroner of Harry’s death – claiming it was ‘expected’ – which meant it was only because of the persistence of the family the inquest took place.
Speaking outside court alongside his tearful wife, Mr Richford said: ‘Today the coroner reached the conclusion that our son Harry died because of a number of serious and preventable failings... that amounted to neglect.
‘Sarah had a textbook pregnancy and Harry was born on his due date. But due to failures in both the delivery and resuscitation of Harry, he died.’
He criticised the trust for trying to ‘avoid outside scrutiny’ and failing to address risks highlighted as far back as 2014.
He said: ‘Had they learned from those cases we wouldn’t be stood here today, because Harry would still be alive and well. We want this to be the turning point so that it does not happen to other families.’
East Kent Hospitals Trust has apologised over Harry’s death. It emerged this week that six other preventable baby deaths may have occurred at the trust since 2016.
Mr Richford added: ‘We are calling on the Secretary of State to order an independent investigation or inquiry into maternity services at the trust.’ Mrs Richford told the BBC: ‘It has been the hardest two years of our life.’
The inquest heard that Mrs Rich
‘We want this to be a turning point’
ford was given a drug to speed up her labour, but at 1.30am the next day concerns were raised about Harry’s heartbeat so staff stopped administering the drug.
A reading raised concerns at 2am and experts said that at this point he should have been delivered within 30 minutes. But it was not until an hour later that the locum
registrar Dr Christos Spyroulis began to attempt to do so using forceps. Harry was eventually born by Caesarean at 3.32am.
The tiny baby had suffered stress due to the chaotic procedure, during which an ‘inexperienced’ locum asked a midwife to move Harry’s head to try to get him out.
After his birth, they attempted resuscitation for 28 minutes, but staff failed to follow guidelines stating they should track timings and take notes during this period.
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 which killed him.
He was only incubated after an anaesthetist stepped in – giving Harry’s parents some precious days to spend with him.
Lawyers for Harry’s family had made a case for unlawful killing but the coroner said the ‘shortfalls were not so flagrant to fall within that definition’. Recording a narrative conclusion, he said the difficult delivery ‘should have been carried out by a consultant’, not a ‘locum on duty that night who was relatively inexperienced’.
He added that Harry’s death was ‘contributed to by neglect’.
Dr Paul Stevens, of East Kent Hospitals Trust, apologised. He said the trust accepted the findings and was ‘committed to learning lessons from Harry’s death’.