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Tearful parents blast NHS Trust after death of their week-old baby

The death of a baby just a week after his emergency delivery was ‘wholly avoidable’ and contributed to by neglect, a coroner has concluded.

Harry Richford died seven days after he was born in November 2017 at the Queen Elizabeth the Queen Mother (QEQM) Hospital in Margate.

Today outside County Hall in Maidstone his father read a statement saying that the trust had tried to avoid outside scrutiny and had failed to learn from this and previous similar cases.

East Kent Hospitals University NHS Foundation Trust, which runs the hospital, apologised over his death and it was reported on Thursday that at least seven preventable baby deaths may have occurred since 2016.

Harry Richford died seven days after he was born. The infant is pictured with his mother, Sarah, and his father, Tom

Harry Richford died seven days after he was born. The infant is pictured with his mother, Sarah, and his father, Tom 

A ‘much desired and much loved baby’, Harry’s mother Sarah Richford had been taken to theatre for an emergency Caesarean section on November 2.

Coroner Christopher Sutton-Mattocks listed a series of errors he found with the care given.

Handing down his conclusion at County Hall in Maidstone, in Kent, on Friday, he said that Harry 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.

Today outside County Hall in Maidstone his father Tom Richford (with wife Sarah) read a statement saying that the trust had tried to avoid outside scrutiny and had failed to learn from this and previous similar cases

Today outside County Hall in Maidstone his father Tom Richford (with wife Sarah) read a statement saying that the trust had tried to avoid outside scrutiny and had failed to learn from this and previous similar cases

Harry Richford (pictured with parents Sarah and Tom) died after an emergency C-section at the hospital in Margate

Harry Richford (pictured with parents Sarah and Tom) died after an emergency C-section at the hospital in Margate 

Referring to the boy’s parents, Sarah and Tom, Mr Sutton-Mattocks 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.’

What were the failings at East Kent NHS? 

The trust at the centre of a scandal over baby deaths failed to deliver Harry Richford on time, 92 minutes after an expert advised he should be.

Harry died at just seven days old after being delivered by C-section on November 2 last year. 

The QEQM also gave Mrs Richford a drug to speed up labour, which hyper-stimulated the infant. 

Archie Batten died on September 1  shortly after being born. His mother had called QEQM to say she was in labour.

But she was told the maternity unit was closed and to drive herself to the trust’s other hospital, Ashford’s William Harvey, 38 miles away.

Four midwives went to her home after the journey was deemed not feasible but they struggled to deliver the baby.

The mother was transferred by ambulance to QEQM, where her son died. His inquest in scheduled for March.   

Archie Powell died at four days old on February 14 after medics treated the twin for a bowel problem.

They failed to spot he had a common infection despite him showing all its symptoms and the delay in treatment sparked severe brain damage.

Tallulah-Rai Edwards was stillborn on January 28. Her mother had become anxious in the 36th week of pregnancy due to her baby’s slowed movement and went to hospital.

Despite struggling to get a good heart-rate reading on the cardiotocography (CTG) machine, midwives sent her home. The baby was found to have died two days later when her mother returned to the hospital.

Hallie-Rae Leek died aged four days old on April 7 2017. A midwife had struggled to find a heart-rate and she was born in a poor condition.

She was resuscitated after 22 minutes but the damage was irreparable.  

There were two stillbirths at the trust in 2016, in March and June. In the first case, the unit failed to recognise that an infant was small given the stage of development. They did not act on suspicious CTG readings and failed to deliver the baby promptly.

In the second case, the trust missed risk factors and failed to properly monitor a CTG and a baby girl died. 

Mr Sutton-Mattocks added: ‘I find that Harry Richford’s death was contributed to by neglect. It was, in my judgment, wholly avoidable.’

Dr Paul Stevens, medical director for East Kent Hospitals: ‘We are deeply sorry and wholeheartedly apologise for our failings in Harry’s care and accept the coroner’s conclusion and findings.’

Harry’s parents had pushed for a judgment of unlawful killing. Although the coroner said he had considered this finding, he concluded that the hospital’s failures were not ‘so large’ as to fall in this category.

It comes as the East Kent Hospitals University NHS Foundation Trust admitted it has ‘not always provided the right standard of care’ in its maternity services.

The inquest heard how Mrs Richford, a teacher, was considered to be ‘low-risk’ during her pregnancy.

After arriving at hospital, Mrs Richford was given a drug to speed up labour over a period of 10 hours – a decision which was criticised by the coroner, as it hyper-stimulated Harry.

She was rushed to theatre after he began to show signs of distress, where medics tried to deliver with forceps before performing an emergency section.

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 locum registrar being assessed, and he had said that he was not asked about his level of experience.

The coroner said staff nurse Laura Guest, who had been called to help with the emergency delivery, 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. Mr Sutton-Mattocks said the situation must have been ‘terrifying’ for Mrs Richford, as there were between 20 and 25 people in the theatre.

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.

‘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.’

Asked about the trust putting measures in place following the inquest, he said: ‘I’m not convinced at present they have the resources and the systems in place today to prevent it.

‘And like I said just now, I hope this case can be a turning point to ensure that this does not happen to anybody else going forwards.’

East Kent NHS Foundation Trust yesterday admitted it has ‘not always provided the right standard of care for every woman and baby in our hospitals’. 

A BBC investigation has unearthed a series of other preventable deaths and poor maternity care. 

Harry Richford died at the hospital in Kent and today an inquest found his death aged one week old was 'wholly avoidable'

Harry Richford died at the hospital in Kent and today an inquest found his death aged one week old was ‘wholly avoidable’ 

Archie Powell died aged four days old on February 14 last year after becoming ill shortly after he was born.

Medics treated the twin for a bowel problem but failed to spot he was suffering from the common infection group B streptococcus despite him showing all its symptoms. 

The delay in treatment sparked severe brain damage and he die at a neo-natal unit in London after transfer. An internal investigation found that the death was ‘potentially avoidable’. 

Tallulah-Rai Edwards was stillborn on January 28 last year. Her mother had become anxious in the 36th week of pregnancy due to her baby’s slowed movement and went to hospital.

Despite struggling to get a good heart-rate reading on the cardiotocography (CTG) machine, midwives sent her home. They said that they were satisfied with what they recorded.

The baby was found to have died two days later when her mother returned to the hospital.

An internal investigation said: ‘The CTG should have been continued for longer and an ultrasound arranged.’

Hallie-Rae Leek died aged four days old on April 7 2017. A midwife had struggled to find a heart-rate and Hallie-Rae was born in a poor condition.

She was resuscitated after 22 minutes, by which point irreparable damage had already been done. The trust apologised after accepting the death was preventable.  

Archie Batten died on September 1 2019, shortly after being born. His mother had called QEQM to say that she was in labour.

But she was told the maternity unit was closed and to drive herself to the trusts other hospital, Ashford’s William Harvey, which is 38 miles away.

Four midwives went to her home after the journey was deemed not feasible but they struggled to deliver the baby.

The mother was transferred by ambulance to QEQM, where her son died. His inquest in scheduled for March.   

There were two stillbirths at the trust in 2016, in March and June. In the first case, the unit failed to recognise that an infant was small given the time he’d been developing. They did not act on suspicious CTG readings and failed to deliver the baby promptly.

In the second case, the trust missed risk factors and failed to properly monitor a CTG and a baby girl died. 

In a lengthy statement to the BBC, the trust did not address any of the cases.

Instead it said: ‘We have been making changes to improve our maternity service for a number of years.

‘Every baby and every family is important to us. We recognise that we need to improve the speed of change.

‘We express our heartfelt condolences to every family that has lost a loved one and we wholeheartedly apologise to families for whom we could have done things differently.’

The Care Quality Commission (CQC) carried out a surprise inspection of trust sites in response to the investigation and a result is pending.  

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