Our investigation has shown numerous failings as you will have read. Sadly, many of these failings are repeated failings and not “one offs”.
Although in Harry’s case, the organisation has been held to account through the judiciary process, no individuals have. We feel that individual accountability is essential to avoid recurrence of the same issues, time and time again.
There are many circumstances whereby we feel individuals, particularly senior clinicians and directors, should be held to account as would happen in any other walk of life –
- Failing to act upon the RCOG report from November 2015.
- Failing to mitigate known risks in maternity as reported in the Trust’s own risk register.
- Failing to call the coroner in Harry’s case even when they knew his death was avoidable from an early stage.
- Allowing consultants close to Harry’s death to investigate their own departments and their own staff.
- The Trust failed to keep the placenta despite this being mandatory as far as the Royal College of pathologists is concerned.
- Failing to notify the coroner of other baby deaths that had to be notified.
- Failure to formally investigate each and every baby death.
- Child death notification form filled out to say that Harry's death was "expected".
- Reporting Harry’s death as expected externally, but an "unexpected outcome" internally.
- Reporting 9 separate “errors” on the statutory MBRRACE report for Harry.
- Failing to carry out meaningful RCA investigations and therefore failing to learn from mistakes.
- Taking on a locum doctor with no checks whatsoever on his skills or abilities.
- Being obstructive to the family in giving a true and honest account of what had happened, duty of candour.
- Failing to supply the required evidence to the inquest in good time, with 1200 pages dumped on the family on day 2 of the inquest.
All of these failings should lead to senior management and directors being personally held to account, to explain how and why these events were allowed to happen and why they failed in their duty as managers.
If this were an outside organisation in the private sector, where avoidable deaths were happening and known to be happening; senior managers and the Board of Directors would be held to account, of that there is no doubt. We have to ask ourselves, why is it so different in the health service?