NHS Trust pleads guilty to failing to provide safe care to baby

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A scandal-hit NHS trust has today pleaded guilty to the ‘wholly avoidable’ death of a baby boy, in a landmark prosecution.

Harry Richford died seven days after his emergency delivery at the Queen Elizabeth the Queen Mother (QEQM) Hospital in Margate.   

An inquest last year ruled Harry’s death in November 2017 was ‘wholly avoidable and contributed to by neglect.’

It 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. 

When he was born ‘silent and floppy’ an anaesthetist had to step in after 28 minutes when a locum registrar failed to get Harry 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.

At Folkestone Magistrates’ Court today, the East Kent Hospitals University NHS Foundation Trust admitted failing to provide safe care and treatment to Harry and his mother. 

Harry’s parents Tom and Sarah Richford, who had to fight for an inquest after the hospital wrongly said their son’s death was ‘expected’, today said they had ‘some sort of justice’ after spending years campaigning for change. 

Mrs Richford said after the hearing: ‘If somebody had done this before Harry was born he may be alive today.’

A coroner last year said Harry’s parents were ‘grieving for a child that should not have died,’ adding: ‘Mr and Mrs Richford were failed by the hospital, but more importantly, Harry was failed.’ 

Harry’s mother, a teacher, was considered to be ‘low-risk’ during her pregnancy.

Mrs Richford had a ‘textbook pregnancy’ and said her son was ‘normal in every way.’ 

After arriving at hospital on November 2, 2017, 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 for an emergency Cesarean after Harry began to show signs of distress, and medics tried to deliver with forceps before performing an emergency section.

Harry should have been delivered within 30 minutes, but was instead delivered after some 92 minutes.

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.

Staff nurse Laura Guest 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. 

The coroner said the situation must have been ‘terrifying’ for Mrs Richford.

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. 

At the inquest into Harry’s death last year, it emerged how the hospital had ‘refused to call the coroner’ and filled out the statutory child death notification form to say that Harry’s death was ‘expected.’ 

Coroner Christopher Sutton-Mattocks found more than a dozen areas of concern in the care of Harry and his mother.

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.

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’. 

Mrs Richford said: ‘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.’ 

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. 

Last year, the hospital trust’s board admitted the number of potentially avoidable baby deaths could be as many as 15 in seven years.

The Healthcare Safety Investigations Branch (HSIB) is currently examining three individual maternity cases.

The trust is currently the focus of an independent inquiry by Dr Bill Kirkup, who led the probe into the Morecambe Bay baby death scandal and also worked on the investigation into the Hillsborough football disaster.

It is looking into the standard of care provided by the maternity and neonatal service at EKH since 2009, the year it became a foundation trust.

Families who believe they received poor clinical care from the trust have been encouraged to come forward and the number is believed to be at almost 200.

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.’

District Judge Justin Barron told Mr and Mrs Richford that he had the power to order an unlimited fine against the trust. Sentencing will take place at the same court on June 18.