A newborn baby’s death a week after his emergency delivery was “wholly avoidable” and “contributed to by neglect”, a coroner has said.
Harry Richford died in November 2017 after being born at Margate’s Queen Elizabeth the Queen Mother Hospital.
His mother, Sarah Richford, had an emergency caesarean but coroner Christopher Sutton-Mattocks listed a series of errors he found with the care given.
Handing down his conclusion, he said that should have been delivered within 30 minutes at 2am – but instead he was delivered at 3.32am – 92 minutes after an expert had advised he should have been delivered.
He also found that an inexperienced doctor was in charge of the birth, and that there was a failure to request support from a consultant earlier.
“They are grieving for a child they believe should not have died,” said Mr Sutton-Mattocks
“I agree with them. Mr and Mrs Richford were failed by the hospital, but more importantly, Harry was failed.”
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He added: “I find that Harry Richford’s death was contributed to by neglect. It was, in my judgment, wholly avoidable.”
It was reported this week that there may have been at least seven preventable baby deaths at the East Kent Hospitals NHS trust – which has apologised for the “devastating loss” of Harry.
Harry’s father says the NHS trust knew there was an ‘extreme risk to pregnant women’
Mrs Richford arrived at hospital on 2 November and was given a drug to speed up her labour – a decision criticised by the coroner because it hyper-stimulated Harry.
She began to show signs of distress and there was a problem identified with Harry’s heartbeat.
Staff tried to deliver Harry with forceps, before doing an emergency C-section.
But he was delivered much later than advised – at 3.32am – by Dr Christos Spyroulis, who the coroner described as “inexperienced”.
Staff nurse Laura Gurst said the scene was “chaotic” and she “didn’t feel it was being strongly led”.
There were around 20 – 25 people in the theatre – a situation the coroner said must have been terrifying for Mrs Richford.
Harry was born “silent and floppy” and need to be resuscitated, the inquest heard.
Anaesthetist Dr Dhir Gurung stepped in after 28 minutes to intubate Harry – an action praised by the coroner because it gave the family seven days with their son – but he had already suffered brain damage.
Sarah and Tom Richford outside Maidstone Coroner’s Court after the conclusion of the inquest
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Sarah and Tom Richford outside Maidstone Coroner’s Court after the conclusion of the inquest
Harry was transferred to a neonatal unit at William Harvey hospital in Ashford but died on 9 November.
Dr Paul Stevens, medical director at East Kent Hospitals, 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… 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 they had made “significant changes” and were working with maternity experts to make “rapid and sustainable improvements”.
Harry’s parents had wanted an unlawful killing decision, but the coroner said the hospital’s failures were not “so large” to justify that.
His father, Tom Richford, said East Kent Hospitals NHS Trust knew there was an “extreme risk to pregnant women and neo-natals in their care” at the time of Harry’s birth.
“This risk was present from at least as far back as 2014, when the number of serious incidents on maternity were highlighted,” he told reporters.
“We have read about Morecambe Bay and Shrewsbury and Telford, and find the similarities to Harry’s case frightening.
“We are calling for the secretary of state to arrange an independent investigation or inquiry into Harry’s death and maternity services at East Kent.”
Watchdog the Care Quality Commission (CQC) said it carried out an unannounced inspection at the hospital this week and its findings would be published as soon as possible.
The trust could face prosecution but the CQV said it had yet to make a decision.
Inspections in 2016 and 2018 had rated East Kent NHS Foundation Trust’s maternity services as needing improvement.
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