The death of a baby seven days after his emergency delivery was “wholly avoidable”, a coroner has ruled.
Harry Richford died a week after he was born at Margate’s Queen Elizabeth the Queen Mother Hospital (QEQM) in 2017.
Coroner Christopher Sutton-Mattocks was told Harry was born not crying, pale, and with no movement in an operating room “full of panicking people“.
Giving a narrative conclusion, he found Harry’s death was “contributed to by neglect”.
Dr Paul Stevens, medical director for East Kent Hospitals NHS Trust, said: “We are deeply sorry and wholeheartedly apologise for our failings in Harry’s care and accept the coroner’s conclusion and findings.”
‘Harry was failed’
Mr Sutton-Mattocks said Sarah and Tom Richford had been excited about becoming first-time parents but had been left grieving.
He 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.”
Mr Sutton-Mattocks criticised the hospital trust for initially saying Harry’s death was “expected”, which meant the coroner was not informed of Harry’s death.
It was only because of the persistence of the family that an inquest was ordered, the coroner said.
He praised Harry’s parents for being “calm and dignified” during the inquest, and added: “Today Harry should be almost two years and three months old… a bundle of energy.
“Instead his family are still grieving and will do so for the rest of their lives.”
‘Damage was done’
Mrs Richford had gone to the midwifery-led unit at QEQM on 31 October 2017. Twenty hours later she was moved to the labour ward and given a drug to speed up labour.
At 01:30 GMT on 2 November, concerns were raised about Harry’s heartbeat.
Three midwives and a senior doctor recalled how it kept dropping and how there were concerns over his position before he was born.
At 02:05 it was decided the baby needed to be delivered, but it was not until an hour later that locum registrar Dr Christos Spyroulis began an attempt to do so using forceps.
Harry was born by emergency Caesarean at 03:32, “to all intents and purposes lifeless”. It took 28 minutes to resuscitate him “by which time the damage was done”, the coroner said.
Obstetrics expert Myles Taylor had told the inquest “but for a failure to deliver at 2am” Harry would have been born in good condition and would have survived.
Dr Giles Kendall, a neonatal medicine expert, said Harry suffered irreversible brain damage and that had resuscitations been of an appropriate standard, Harry would almost certainly have survived.
Explaining his conclusion, Mr Sutton-Mattocks said he considered the divergences of unlawful killing or neglect.
“I do not conclude the failures were so large and so atrocious as to fall within the definition of unlawful killing.”
But he said there were failures by a number of people, some of whom lacked the experience for the positions they were in.
Errors found by the coroner
- Hyper stimulation from excessive use of Syntocinon, a drug that speeds up labour.
- Once the Cardiotocography (CTG) heart reading had become pathological by 02:00 Harry should have been delivered within 30 minutes, not 92 minutes.
- Delivery itself was a difficult one and should have been carried out by a consultant who should have arrived earlier than she did.
- Locum was inexperienced and was not properly assessed, if at all.
- There was a failure to secure an airway.
- Failure in not requesting consultant support early enough during resuscitation attempts.
- Failure to keep proper account of time keeping and resuscitation attempts.
When Harry was less than nine hours old he was transferred to a neo-natal intensive care unit in Ashford where he survived for a week with the aid of life support.
His parents were told he would never be able to feed himself or walk, so the advice from the consultant was that they withdraw his care
Speaking to the BBC, Mrs Richford said she and her husband were unable to hold their son “until the day that he died”, and the seven days during which he had survived had been “the worst week” in their life.
“Harry was perfect when we saw him and to have to withdraw the care from your baby and to live with that afterwards… it’s a whirlwind of negative emotions to try and cope in everyday life.
“It has been the hardest two years of our life,” she said.
On Thursday it was revealed that at least seven preventable baby deaths may have occurred at the East Kent Hospitals Trust since 2016.
The trust was placed into special measures in 2014 following an inspection by the Care Quality Commission (CQC) which rated its care, including maternity services, as inadequate.
Subsequent CQC reports have rated it as “requires improvement”.
Ted Baker, chief inspector for hospitals, said the commission was aware of the conclusion of Harry’s inquest, and it had conducted an unannounced inspection of the trust’s maternity services on Wednesday and Thursday.
“CQC’s investigation is ongoing and no decision has been taken at this stage on whether we will prosecute the trust for a failure to provide safe care or treatment resulting in avoidable harm or a significant risk of avoidable harm,” he said.
Dr Paul Stevens, medical director for East Kent Hospitals NHS Trust, said: “We are so sorry and apologise wholeheartedly for the devastating loss of baby Harry.
“We fully accept that Harry’s care fell below the standard that we want to offer every mother giving birth in our hospitals.
“Mr and Mrs Richford’s expectation in November 2017 was that they would welcome a healthy baby into their family and we are deeply sorry that we failed in our role to help them do that.
“With great sadness we accept that we failed Harry and his family, and apologise unreservedly.
“We are also truly sorry that Harry’s family was not given the support and answers they needed. We deeply regret the extra pain that our delays have caused them.”
Dr Stevens said the trust fully accepted the coroner’s findings and recommendations, and it was “committed to learning the lessons from Harry’s death”.
After the hearing, Mr Richford said: “Our son 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 as a result of the failure to resuscitate him, he died.”
Mr Richford added the trust had tried to avoid outside scrutiny by refusing to call the coroner, despite being asked numerous times, and had said Harry’s death was “expected”.
He said: “Accidents happen every day but failing to learn from them appears to have become part of the culture of this trust. It was known there was a risk. The risk was present as far back as 2014.”
Mr Richford said the trust “failed to mitigate the risk despite the risk being a real risk to life”.
He said: “We are calling on the secretary of state to order an independent investigation or inquiry into maternity services at East Kent.”
A Department of Health and Social Care spokesperson said: “We can never underestimate the agony of losing a baby and our thoughts are with Harry’s family following the tragic loss of their son.
“An extensive programme of support is in place to improve the maternity services at the Trust and we will continue to closely monitor the actions and progress.”