2nd November 2017 - 9th November 2017
A family's fight for truth and justice
"I’m not just one voice, I am the voice for all those who have suffered at the hands of the Trust and their inadequate maternity department. We respectfully ask the Coroner to consider the fact that it is the family’s real wish to seek justice for all of those that have been in this position."
From Tom Richford's statement to the Coroner - January 2020
On July 20th 2023 the Government published it's response to Bill Kirkup's report on East Kent. You can read the details HERE
"The review was launched because of concerns about the quality of care being provided by the Trust." - "I’m determined to see safety standards in maternity and neonatal care improve across the country. While this invaluable report focuses on the situation in East Kent, I want to see its recommendations implemented nationwide." Maria Caufield - Health Minister
This investigation and the actions that followed, all started with Harry's case being highlighted to the authorities by us, his family.
On 26th May 2023, the CQC downgraded East Kent Maternity to inadequate.
How, with all of the scrutiny and input from NHSE can this be possible. Who is accountable? Who will deal with the wholly inadequate situation in East Kent, that has been so for over a decade.
The Kirkup Report was released on October 19th 2022 and can be read HERE "What has happened in East Kent is deplorable and harrowing."
From the Kirkup report directly speaking of Harry's case -
1.112 This pattern of behaviour by the Trust, clearly evident in this case, recurred in many others that we examined. It included denying that anything had gone amiss, minimising adverse features, finding reasons to treat deaths and other catastrophic outcomes as expected, and omitting key details in accounts given to families as well as to official bodies. Although we did not find evidence that there was a conscious conspiracy, the effect of these behaviours was to cover up the truth.
1.113 Even had none of the previous failings been known – and they were – baby Harry’s death should surely have been a catalyst for immediate change. In fact, it required public remonstration by a coroner over two years later, precipitated by the persistence, diligence and courage of baby Harry’s family, to reveal an organisation that did not accept its own failings, considered itself above scrutiny or accountability, and consistently rejected the opportunity to learn when things went wrong.
Harry was born on his due date, November 2nd 2017 at Queen Elizabeth the Queen Mother (QEQM) hospital in Margate Kent (EKHUFT) following a text book pregnancy, he was normal in every way. Everyone expected a normal birth and Sarah was classified as low risk. Harry died 7 days later, following a botched labour, delivery AND resuscitation.
This website is dedicated to our Harry and describes what happened
during his mother Sarah's labour, Harry's birth, and how we as a family had to battle for over 2 years to find the truth, justice, peace and some level of closure; whilst trying to hold those responsible to account to ensure lessons are learnt for all future families.
The Trust refused to call the coroner for nearly 6 months despite telling us his death was avoidable. In the end, we did it ourselves. Over 2 years later, on January 24th 2020 the Coroner gave his conclusion to Harry's 3 week Article 2 inquest. There were 7 gross failings that he ruled, amounted to neglect. Full details of his findings are on our Inquest page.
On October 9th 2020 The CQC announced that they would be criminally prosecuting the Trust on two counts of unsafe care and treatment for Harry and Sarah Richford. Details Here. This is the first time in the UK than an NHS Trust has been prosecuted for unsafe clinical care. The criminal case went before District Judge Barron on Monday 19th April 2021 in Folkestone Kent, and the Trust entered a plea of Guilty. Sentencing followed on June 18th. and the Trust were fined £733,000 after discounts (£1.1 million gross).
District judge Justin Barron told Harry's mother, Sarah Richford, and her husband Tom: "The trust fell far short of the appropriate standards of care and treatment in dealing with you."
"However, it took a skilled, determined, grieving family's fight for justice to force meaningful change on a reluctant and failing organisation." Michael Buchanan BBC
The Kirkup Inquiry
The Kirkup Independent Inquiry began a detailed inquiry in April 2020 and will publish their findings on September 21st 2022 It is understood that numerous families have given detailed evidence to the inquiry panel and of those, well over 200 have been included in their investigation.
East Kent Hospitals (EKHUFT) Maternity - Chronology
August 2013 - Local CCG raise issues about serious incidents in Maternity. HERE (page 2 at the bottom)
November 2015 - RCOG full Audit finds major issues. HERE
November 2nd 2017 - Harry Richford is born and dies 7 days later.
From November 9th for nearly 6 months - the Trust refuse to call the coroner.
March 15th 2018 - the family report Harry's death to the coroner.
February 2020 - CEO Susan Acott speaks to the BBC saying Harry's death will change the Trust. HERE (at 4 minutes) - "We genuinely have to use the memory of Harry Richford, to say we will learn, we will do better and we won't let this happen again.........and that is my job and that is what I am committed to do"
February 2020 - Other Parents talk on Radio Kent about issues since 2011 - HERE
April 2021 - The Trust plead guilty to the criminal charges brought by the CQC and are later fined £733,000
September 2021, Susan Acott resigns as CEO and is replaced in April 2022 by Tracey Fletcher HERE
One year on from Dr Bill Kirkup's "Reading the Signals" report, here is what the media reported at that time and a statement from the Trust, released this week.
There is a lot of work being carried out as a direct result of Harry's death, the Kirkup report and all of the other babies who have suffered; as well as their families who have been brave enough to speak up.
There is still a huge amount to do, and the Trust must not relax now.
More details on the Kirkup Report HERE
Harry's parents, Sarah and Tom are both PE teachers, physically fit and non-smokers, Sarah didn't drink alcohol at all during her pregnancy. Harry's was born on his due date which was November 2nd 2017, he was a perfectly normal child and the post mortem 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, she was classed as "Low Risk". At 4am the next morning her waters were broken by a midwife however, 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 by the registrar to induce Harry's birth but the midwives didn't agree with the doctor as they were concerned with her CTG readings, one midwife even pressed the emergency buzzer, however, the junior doctor said to go ahead. Sarah was dressed in a theatre gown and stockings as one midwife told her that she would need an emergency C-section. She did, but it didn't happen for a further 14 hours. Eventually, after around 3 hours they started the Syntocinon but there was no escalation from the junior doctor or midwife coordinator to the consultant.
At no point during Sarah's labour was she seen by any consultant or any doctor above an ST3 - which is 1st year as a Registrar. 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 only 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 at all, in fact, no one at the Trust had even seen his CV. Instead, he had been recruited from an agency who seemingly had blanket authority to fill vacancies. 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 of this. He was later disciplined by the GMC for poor clinical practice.
By 02.00 on November 2nd the CTG scans were becoming really concerning, described as "pathological" and the Registrar called the consultant on call at home to notify her of his intentions to attempt 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 are clear and say that she had to attend. It was not for the Registrar to say he was ok. The forceps didn't lock but he was using standard non-rotational forceps which were entirely the wrong type.
The locum Registrar then decided upon a C-Section. Harry’s head was impacted as Sarah had been left so long on the inducing drug Syntocinon. The increased pushing, caused by the drug had impacted his head into Sarah's pelvis and he was unable to turn. At inquest it was revealed that Sarah had in fact been overdosed on Syntocinon by the midwives for 10 hours. 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 by clinical staff at inquest as having an atmosphere of chaos and panic.
Eventually at 03.32 Harry was born. He was passed to a Paediatric Registrar ST3 and GPST1. This junior registrar and his GPST1 were unable to intubate or resuscitate adequately at all, at inquest the registrar admitted being "out of his depth". Eventually at approximately 03.57 the anaesthetist in attendance for Sarah got up and intubated Harry without any problem. At inquest, the coroners expert witness said that based on Harry's case he would have failed the entire team on even 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 unwell, he had sustained severe brain damage. Following an MRI showing he would have had significant learning and cognitive difficulties and would be 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, Consultants and the Board of Directors, who were very much aware of the failings, in great detail, for years prior to Harry's birth. The Trust's Root Cause Analysis investigation failed to find the root cause and as a result, failed to learn. Our investigation has shown that the Trust have continually failed to learn from such cases, many of which were way before Harry was even born.
In 2015, 2 full years before Harry was born, the Trust had an invited review from the RCOG, it showed multiple failings and safety concerns. The same concerns caused Harry's death 2 years later. However, over 4 years later, the Trusts own internal review showed that of 23 concerns raised in the RCOG reviews, only 2 were fully met. The Board of directors and senior management were derelict in their duty, as a result, Harry and many other babies died or were harmed.
Shine bright little one, you will never be forgotten; your life has made a difference.
We then discovered a full Royal College (RCOG) audit of the East Kent Trust's (EKHUFT) maternity services from 2015, 2 full years before Harry was born, it's introduction tells you all you need to know. (Full Report Here)
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. That year's claim has now been investigated and the Trust have been found to have mis-declared the results. The truth was 6/10 not 10/10 for both years and the Trust have been ordered to repay funds awarded. The subsequent years claim 2018/2019 was also rejected as it was checked and found by NHSR to be a false claim. details HERE. (note tabs at the base).
Quote from Sir Roger Gale MP
“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." full text HERE
On 13th February 2020 Sir Roger Gale MP spoke emotionally in parliament about East Kent Baby Deaths and the need for an inquiry - HERE
Arnold & Porter LLP Quote (they represented us at Inquest)
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. full text HERE
Brick Court Chambers Quote (they represented us at Inquest)
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. Full text HERE