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Kent baby death 'wholly avoidable'.

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 Queen Elizabeth the Queen Mother Hospital (QEQM), Margate, 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, the coroner found Harry's death was "contributed to by neglect.”

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 his death. Only the persistence of the family led to an inquest being ordered, the coroner said.

He 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."

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 that there were concerns about 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, tried 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, told the inquest "but for a failure to deliver at 2am" Harry would have been born in good condition and would have survived.”

A neonatal medicine expert, Dr Giles Kendall, said Harry suffered irreversible brain damage and that, if resuscitations had been of an appropriate standard, he would almost certainly have survived.

Explaining his conclusion, Mr Sutton-Mattocks said he considered the divergences of unlawful killing or neglect but added: "I do not conclude the failures were so large and so atrocious as to fall within the definition of unlawful killing."

He said there were failures by a number of people, some of whom lacked the experience for the positions they were in.

Errors which the coroner identified included: 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 was difficult and should have been carried out by a consultant who should have arrived earlier; the locum was inexperienced and was not properly assessed, if at all.

Others errors included that there was a failure to secure an airway; a failure in not requesting consultant support early enough during resuscitation and a failure to keep proper account of time keeping and resuscitation attempts.

When Harry was under nine hours old he was transferred to a neo-natal intensive care unit in Ashford where he survived for a week with life support.

His parents were told he would never be able to feed himself or walk, so the consultant’s advice was that they withdraw his care

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.

She added: "Harry was perfect when we saw him and to have to withdraw the care from your baby, and to live with that afterwards, is a whirlwind of negative emotions to try and cope in everyday life. It has been the hardest two years of our lives."

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 the trust as "requires improvement". CQC chief inspector for hospitals, Ted Baker, 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.

He said: "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."

Dr Stevens added: "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 added that 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: "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."

He claimed that 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. We are calling on the Secretary of State to order an independent investigation or inquiry into maternity services at East Kent."

 

The contents of this article are intended for general information purposes only and shall not be deemed to be, or constitute legal advice. We cannot accept responsibility for any loss as a result of acts or omissions taken in respect of this article.