2nd November 2017 - 9th November 2017
Harry was born on his due date at Queen Elizabeth the Queen Mother (QEQM) hospital in Margate Kent following a text book pregnancy, he was normal in every way. Everyone expected a normal birth and Sarah was classed as low risk. Harry died 7 days later after life support was removed.
This website is dedicated to Harry and describes what happened
during his birth and the following months and years while we engaged in an uphill battle to find the truth and to find our way to justice, peace and closure; whilst holding those responsible to account to ensure lessons are learnt for all future families.
On January 24th 2020 the Coroner gave his conclusion to Harry's 3 week inquest, there were 7 gross failings that he said amounted to neglect. Full details of these findings are on the Inquest page.
The Kirkup Independent Inquiry has now started and they are keen to hear of the experiences you have had in the maternity departments of QEQM and William Harvey Hospitals since 2009. Families are encouraged to get in touch with Dr Kirkup should email Ann Ridley at firstname.lastname@example.org or Ken Sutton at email@example.com or 07854 575 358 in total confidence, your details will never be shared without your permission.
Harry's parents, Sarah and Tom were both PE teachers, physically fit and non-smokers and Sarah didn't drink alcohol during her pregnancy.
Harry's was born on his due date which was November 2nd 2017, he was a perfectly normal child and the postmortem carried out at St Thomas' Hospital London could find no issues at all describing him as grossly unremarkable.
Sarah was admitted into the Midwife Led Unit (MLU) on October 31st 2017. By 11am the following day she was transferred to the main consultant led Maternity ward due to lack of progression as Harry was back-to-back.
Sarah was prescribed Syntocinon to induce Harry's birth but the midwives didn't agree with the doctor as they were concerned with her CTG readings, the junior doctor said to go ahead. Eventually, after around 3 hours they started the Syntocinon but there was no escalation from the junior doctor to the consultant.
At no point during Sarah's labour was she seen by a consultant or any doctor above an ST3 - 1st year specialisation. You have to get to ST7 before becoming a consultant.
After Sarah had been in hospital 25 hours a locum ST3 doctor took over the running of the O&G department. He was on his 3rd ever shift for the hospital and had been given no induction into the O&G department. It later transpired that he had not been assessed by anyone clinical at all, in fact, no one had even seen his CV. Instead he had been recruited from an agency by an administrator in Ashford. This locum had only been a registrar for 9 months and was very inexperienced, but nobody at the Trust including the consultants he was working with had any idea. He was later disciplined by the GMC.
By 02.00 on November 2nd the CTG scans were becoming really concerning and the Registrar called the consultant on call at home to notify her of his intentions to go for a trial of instrument delivery or a C section if this was not successful, the consultant asked if he wanted her to come in but he said no. RCOG rules say she should have attended, it was not for the Registrar to say he was ok.
The locum Registrar then went for a C-Section. Harry’s head was impacted as Sarah had been left so long and on the inducing drug Syntocinon and the increased pushing had impacted his head. At inquest it was revealed that Sarah had in fact been overdosed on Syntocinon by the midwives. The locum then got his very junior SHO to extend the cut even though she told him that she had never done this or any other surgery ever before. The theatre was later described as having an atmosphere of chaos and panic.
Eventually at 03.32 Harry was born. He was passed to a Paediatric Registrar and GPST1. The registrar and GPST1 were unable to intubate or resuscitate adequately at all, at inquest the registrar admitted being "out of his depth". Eventually at 03.56 approximately the anaesthetist in attendance for Sarah got up and intubated Harry without any problem. At inquest, the coroners expert witness said that he would have failed the entire team on the most basic of neonatal resuscitation courses.
The switchboard had outdated rota sheets and called two incorrect numbers before reaching the paediatric consultant on call, who later arrived but too late to help Harry.
It was found during the inquest that by this time Harry was very seriously ill and had sustained severe brain damage due to individual and gross systemic failings at the hospital. Following an MRI showing he would have had significant learning and cognitive difficulties and been a paraplegic, at just 7 days old and following advice, life support was removed.
Harry was failed by every department at the Trust, Maternity, Obstetrics, Neonatology and then their Root Cause Analysis investigation that failed to find the root cause. Shine bright little one, you will never be forgotten.
Our reading and research led us to find The Morecombe Bay maternity scandal centred around Joshua Titcombe, the similarities were, in some regards uncanny. This scandal was also investigated by Dr Bill Kirkup who published his report in March 2015.
We then discovered a full RCOG audit of the East Kent Trust's maternity services in 2015, 2 full years before Harry was born, it's introduction tells you all you need to know -
This review has been commissioned by Dr Paul Stevens, Consultant Nephrologist and Medical Director of East Kent Hospital’s University NHS Foundation Trust, following concerns about the working culture within women’s health services including relationships and communication between midwives and obstetricians. Issues of concern are an inconsistent compliance with national standards amongst obstetricians, poor governance in relation to serious incidents, staffing, education and supervision of obstetric middle grades and trainees and consultant accessibility and responsiveness. Concerns relating to consultant presence on the delivery suite as per RCOG recommendations have also been raised.
We also discovered that the Trust had claimed £1.2 million from the NHS as a rebate during the exact period of Harry's birth by certifying they were 10 out of 10 for maternity safety. This is now being investigated.
Quote from Sir Roger Gale MP full text HERE
“There have been many failings, both medical and administrative, in this case. The Coroner has determined that Harry`s death was avoidable and I believe that in the early stages the hospital authorities were obstructive in their efforts to prevent the facts from being established. What should have been a straightforward process therefore contributed to the family`s ordeal."
Arnold & Porter LLP Quote full text HERE
This is one of the first cases against an NHS Trust in which Article 2 of the European Convention of Human Rights has been recognised as being engaged, due to the systematic and structural failings at the Trust. The Trust was aware of the risks in both the obstetrics and neonatology services two years before Harry's birth, but had not put in place any training or procedures to avoid those risks arising. It is rare for a Coroner to find that a death in an NHS context amounts to neglect as this is a high evidential burden.
Brick Court Chambers Quote Full text HERE
Following an earlier ruling in which Article 2 of the ECHR had been found to be engaged, the learned Coroner ruled today that Harry Richford’s death was wholly avoidable, and had been caused to by numerous gross failings on the part of the East Kent University NHS Trust, which amounted to neglect.
I would ask that you read Harry's story, as much or as little as you wish but please - "go into hospital with your eyes wide open"
Harry's Grandad ~ Canterbury ~ Kent