• Series of failing in care of new-born at East Kent Hospitals University FT
  • Coroner to recommend national review of locums in maternity wards
  • Trust already subject to criminal investigation by the Care Quality Commission over the case
  • The regulator had not seen a damning report into earlier failures at the trust’s maternity services

A string of failures amounting to neglect led to the death of a new-born baby, a coroner has ruled today.

Harry Richford died a week after his delivery at Margate’s Queen Elizabeth, the Queen Mother, Hospital – part of East Kent Hospital University Foundation Trust – in November 2017.

An inquest into his death was held this month after the intervention of the chief coroner for England, as the death was originally treated as expected by a doctor at the trust and not reported to the coroner.

Coroner Christopher Sutton-Mattocks said the case did not meet the very high standard of evidence needed to record a verdict of “unlawful killing” but that it was contributed to by neglect. Harry’s family called for a public inquiry outside the court.

Mr Sutton-Mattocks is to recommend there should be a national review of the assessment of locums in maternity wards after hearing there was no evidence that this had happened in this case.

The failings listed included:

  • Harry’s mother Sarah suffered uterine hyperstimulation due to “excessive” use of a drug used to speed up labour.
  • She should have been given a Caesarean section within 30 minutes when the foetal heartbeat trace became “pathological”. It was 92 minutes before the baby was delivered.
  • The delivery should have been carried out by a consultant – who should have attended the difficult birth earlier after being made aware of the problems. In fact, it was carried out by a locum with limited experience. This locum had not been properly assessed, if at all, and should not have been put in this situation without supervision, the coroner said.
  • A failure to secure Harry’s airway when he was delivered apparently lifeless and “resuscitation…failed to be of an appropriate standard”. There was a failure to recognise early enough that consultant support in resuscitation was needed. It took 28 minutes to intubate him.
  • A failure to keep account of the time passing during resuscitation, despite 20 or 25 people being in the room.

The coroner praised an anaesthetist who was caring for Ms Richford, who was aware of the chaos in the room, at this point. He put her under a general anaesthetic and then helped to intubate Harry. The paediatric consultant, who was sleeping in her office rather than at home, also attended swiftly once called – but it took three attempts to contact her because the switchboard had the wrong details for the on-call consultant.

Earlier the inquest had been told by expert witnesses that Harry would have lived had he been delivered earlier and that, had he been swiftly resuscitated, would probably not have suffered any irreversible brain damage from lack of oxygen if resuscitation had been of an appropriate standard.

HSJ reported on Wednesday that the CQC was carrying out a criminal investigation of EKHUFT over the case. It had initially denied this but backtracked on Friday.

Harry’s death came more than 18 months after a Royal College of Obstetricians and Gynaecologists report which revealed

  • Some consultants in the maternity department at Queen Elizabeth, the Queen Mother, Hospital failed to conduct daily labour ward rounds, review women, make plans of care and attend out-of-hours.
  • Major clinical guidelines did not reflect evidence-based practice.
  • Staff felt there was no point in reporting safety concerns as the trust would not take action and maternity services were not “on the priority list at board level.”

The report – which was not shared with the CQC for three years – examined seven “index cases” – in which two babies died – and another 16 cases, including a number of severe post-partum haemorrhages. Cases included delays in providing interventions, junior doctors dealing with serious complications without senior support, and cases where foetal heartbeat monitoring was delayed.

The trust’s maternity servies are currently rated “requires improvement”.

The CQC confirmed it had carried out an unannounced inspection of the trust’s maternity services yesterday and on Wednesday.

CQC chief inspector for hospitals, Ted Baker, said in a statement: ”CQC’s 2016 inspection rated maternity services at EKHUFT as ‘requires improvement’, identifying that staffing levels were impacting on the quality of patient care. That rating remained unchanged at our 2018 inspection, during which it was noted that the department had changed its approach to foetal monitoring training after concerns were identified.

“The trust remains subject to close monitoring and further inspections.”

The 2015 Kirkup report into maternity failings at the University Hospitals of Morecambe Bay FT recommended that external reports should be shared with the CQC. The Department of Health said it would consult on this but that has not happened.

The trust said in a statement: “We are truly sorry for the death of baby Harry and our thoughts and deepest sympathies go out to Harry’s family.

“We accept that Harry’s care fell short of the standard that we expect to offer every mother giving birth in our hospital and we are fully cooperating with the CQC’s investigation into Harry Richford’s death.”

At the conclusion of the case, the coroner called consultant obstetrician and gynaecologist Anastasia Goumenou, who had given evidence earlier in the hearing as the on-call consultant at the time of Harry’s birth. Ms Goumenou had then discussed elements of the case with colleagues at the trust, despite the coroner having said this should not happen – a potential contempt of court.

Ms Goumenou said this had happened when she was distressed and “only wanted to help” but the coroner said her action had led to delays in the case, the need to find counsel for her at short notice, and prolonged the agony for Mr and Mrs Richford.

However, he decided to take no further action against Ms Goumenou.

Timeline of events at the trust

June 2013 – Paul Stevens appointed medical director.

August 2014 – Trust put into special measures after CQC inspection finds it inadequate.

March 2015 – Longstanding chief executive Stuart Bain retires. Chris Bown appointed as interim chief executive. The trust later initiated a Royal College of Obstetricians and Gynaecologists report into its obstetrics services.

April 2015 – Nikki Cole appointed chair to replace Nicholas Wells.

November 2015 – Trust rated “requires improvement” by CQC but remains in special measures.

January 2016 – Matthew Kershaw takes up role as chief executive.

February 2016 – RCOG report completed.

December 2016 – CQC maintains “requires improvement” rating and recommends trust leaves special measures.

March 2017 – Trust exits special measures for quality.

September 2017 – Mr Kershaw steps down after poor A&E performance, along with chair Nikki Cole. Susan Acott, then chief executive of Dartford and Gravesham Trust, takes on the role on an interim basis the following month. Peter Carter appointed interim chair.

November 2017 – Harry Richford dies.

March 2018 – Professor Stephen Smith appointed chair.

April 2018 – Ms Acott takes on the chief executive’s role permanently.

September 2018 – Trust rated “requires improvement” by the CQC.

January 2019 – The RCOG report is shared with the CQC.

February 2019 – Children’s services at the QEQM found to be inadequate by the CQC.

January 2020 – Harry Richford inquest starts.