Coroner’s 19 proposals

A coroner has published 19 recommendations for improvements at East Kent Hospitals maternity units following the “wholly avoidable” death of baby Harry Richford. Christopher Sutton-mattocks last month ruled after a threeweek inquest that the baby boy, whose parents Tom and Sarah are from Birchington, was “failed by the hospital”. Harry was born at the QEQM on November 2, 2017, after an emergency caesarean, performed by an inexperienced locum. He later died at the William Harvey Hospital.

In a report published on Monday, Mr Sutton-mattocks sets out 19 recommendations for improvements focusing on the recruitment, assessment, supervision and record-keeping relating to locums, with an emphasis on the “permitted scope” of activities before they are left responsible for out of hours care. He also recommended a review of procedures relating to consultant attendance.

A baby boy died after his mother was turned away from the QEQM hospital in Margate while in labour due to the maternity unit being shut. Instead, Archie Batten’s mum was advised to go to the William Harvey Hospital in Ashford - 38 miles away.

But she started to give birth at home with a “poor quality of care by midwives” who went to assist, according to the family’s lawyer.

The details emerged at a pre-inquest review at Archbishop’s Palace in Maidstone on Monday into the death of Archie, who died on September 1 last year shortly after birth. Archie’s death raises further questions over the lack of maternity services on offer in the east of the county, with the Kent and Canterbury hospital being stripped of its birthing unit.

The future of maternity services is currently being scrutinised as top clinicians consider whether to give the go-ahead for a ‘super hospital’ in the city. If agreed, then the service would be centralised in Canterbury and scrapped from Margate and Ashford.

During the inquest proceedings, the family’s legal representative, Nick Fairweather, said Archie’s mum should never have been sent away from the Margate unit, which had gone into ‘divert’ mode due to lack of beds and was not taking in any more patients.

He said: “At 2.35pm, when she was turned away from hospital she was told she could access services at any time if needed,” he said.

On her return at 4.50pm, he said she was told the hospital was in shut down.

“She should never have been sent away in the first place,” he said.

He also criticised the quality of care by the four midwives that assisted Archie’s mother at home.

“What they failed to do was so fundamental they were not providing a meaningful service at all,” he said. Assistant coroner Sonia Hayes said the root cause analysis (RCA) investigation found she should not have been sent home in the first place.

“If she hadn’t had been, the ‘divert’ wouldn’t have affected her,” she added.

It was also heard there was incomplete record-keeping during her labour.

Ms Hayes is considering whether to hold an Article 2 inquest, which is an enhanced hearing, possibly with a jury, but will wait for more evidence before making a decision. She also criticised the trust during the pre-inquest review for failing to submit documents in time, including Archie’s medical notes and an up-to-date full disclosure document.

A full inquest is expected in the coming months.

‘She should never have been sent away in the first place’