It is really important to us that Harry's death and the huge sacrifices made by Sarah, Tom and the wider family have led to long term change all over the NHS. Here we want to highlight key things that we believe would not have happened if Harry had not been born and the family hadn't demanded the truth.
In his 7 short days on this planet, Harry has changed the world of maternity care here in East Kent and the wider NHS in a really positive way.
East Kent has turned into one of the UK's biggest maternity scandals and ranks alongside Morecombe Bay, Shrewsbury and Telford, and now Nottingham. (see Donna Ockenden's inquiry page - http://www.donnaockenden.com/the-ockenden-review-sath/).
Without our Harry, these gross failings and cover ups would have continued as they had for years before. There will be families who we have helped who will never know that they could have been a victim of these issues.
The Kirkup Inquiry. The Kirkup team reported in October 2022 and shows the most disturbing findings of poor practice and cover up in maternity services. Once these gross failings are exposed to public and media scrutiny the East Kent Hospitals Trust can never go back to what it was. There is no doubt that without Harry's short life and the persistence of his parents and grandparents, this investigation would not have taken place. See our Kirkup page
CQC Criminal Prosecution. The first ever criminal prosecution of an NHS Trust for unsafe care and treatment in a clinical setting will, we feel sure be a mark for this Trust and the entire NHS that such appalling care will not be tolerated again. On April 19th 2021 the Trust entered a plea of guilty for unsafe care and treatment of Sarah and Harry. We hope this will mean that other Trusts will react VERY differently before allowing maternity services to deteriorate so badly.
Coronial oversight. As a direct result of Harry's case, the senior coroner for Kent said - "The investigation of Harry’s tragic death has not only exposed a number of failures within the East Kent Hospital Trust but has also led to the discovery that deaths of babies within the Trust which should have been referred to the Coroner at the time of the death had not been. These concerning events, as the inquest found, should never have happened." and went on "I am of course now aware of a number of historic baby deaths that were not referred to the Coroner at the time." - We now know that the coroners office will have far more scrutiny of baby and maternal deaths here in East Kent.
RCOG Locum Passport. The Royal College of Obstetricians and Gynaecologists have carried out a major work stream on locum employment and have confirmed that Harry's Inquest was a key driver in this work. The initial policy work is HERE and in due course details of the "Locum Passport" will be published that will give policy on locum experience and supervision.
Panorama. We were able to tell Harry's story on BBC's highly influential Panorama. Being able to show the circumstances surrounding Harry's birth and death on this platform has helped to ensure that Maternity services, not only East Kent but the wider NHS are front of mind for government and NHS leaders. Link to Panorama
Baby Death Reduction. Since Harry's inquest in January 2020 and the furore that followed, an expert maternity team were sent to the Trust. Neonatal deaths in the full year 2020 fell by 55% compared to the previous 7 year average and still births by 20% (see table at the base of this page). This demonstrates clearly how, with the correct focus, leadership and procedures lives can be saved. Had the Trust followed the RCOG audit diligently in early 2016 over 40 babies lives could have been saved in the first 4 years and we include Harry in this figure.
Sadly, in 2021, neonatal deaths and still births increased by 25% when compared to 2020. This is a sad indication that, despite the extraordinary focus on this Trust's maternity services, they seem unable to keep up the progress that was made when the senior advisors were sent in after Harry's inquest. Lates FoI han be seen HERE
Patient Safety Congress. Harry's grandfather Derek Richford, was invited to speak alongside Donna Ockenden and Sarah-Jane Marsh (NHS England) at the 2021 Patient Safety Congress in Manchester. He was able to tell the family's story to around 1,000 delegates. These consisted of senior managers and Patient Safety Champions as well as other influential roles within patient safety and investigations within Trusts. It is hoped that the telling of Harry's Story will be heard and relayed back to Trusts in order aid learning. The key message was "Denial is the key factor in the failure to learn" and "Never waste a mistake". You can see the whole session HERE
Derek was also invited to speak at the Baby Lifeline conference in Birmingham in September 2022. The audience included Dame Ruth May, Professor Jacqueline Dunkley-Bent, Matthew Jolly and a host of other clinical specialists. Derek's theme here was "Denial is the biggest thief of learning" this phrase has since been repeated throughout the NHS as a call to action - You can see the presentation HERE
PHSO Complaint Handling. Harry's story has led to a great deal of reflection within the Parliamentary and Health Service Ombudsman service, regarding how they deal with complaints of this nature. Harry's grandfather Derek, was able to speak directly to the Ombudsman, Rob Behrens CBE to describe how PHSO and others had failed our family. This should lead to important changes and improvements. You can hear the interview HERE you can also see a session from the Patient Safety Congress HERE that includes The Ombudsman and Derek (at around 16 minutes in).
CQC Inspections. After we forced Harry's story into the spotlight, the CQC have put a new emphasis on maternity department inspections. As at October 2023, half of ALL maternity departments in England are rated as Inadequate or Requires improvement - HERE "This year, we continue to have concerns around the quality of maternity services. Ten per cent of maternity services are rated as inadequate overall, while 39% are rated as requires improvement. Safety and leadership remain particular areas of concern, with 15% of services rated as inadequate for their safety and 12% rated as inadequate for being well-led."
Before Harry's case, the first ever CQC prosecution for unsafe Care and Treatment in a clinical setting, there inspections had not uncovered such failings. We believe it is Harry's name that started their change of emphasis. Before Harry, the figure of Inadequate was 3%, so we have a 3 fold increase. HERE Page 24
New Inquests for maternal deaths - Through Harry's story Michael Buchanan and James Melley from the BBC investigated two maternal deaths from 2018. These deaths were not afforded an inquest at the time as the coroner was persuaded that the two cases were not connected. Michael and James investigated and found that the Trust were aware the cases were linked and were working on that basis with Public Health England. However, they had not admitted this to the families or coroner. On December 30th 2021 the senior coroner for Kent announced that the ladies would now be given full inquests. We firmly believe that without Harry's death, this action would not have happened. The inquests will now take place at the end of February 2023. BBC Story HERE
Recognition by Clinical Negligence Lawyers, maybe this will assist others (Tozers) -
“This was a landmark prosecution but at its heart was the tragic and avoidable loss of baby Harry Richford’s life at East Kent Hospitals NHS Foundation Trust in 2017.”
“Harry’s grieving parents’ concerns about the standard of care he and his mother Sarah received were swept under carpet and they had to persist in a fight to get to the truth of the Trust’s failings. The Trust was more concerned about its reputation than improving standards of care but, as a result of the brave parents battle, neonatal deaths at the Trust have fallen by 55% since 2020 and still births have fallen by 20%.”
“The case not only demonstrates the importance of questioning standards of care when healthcare failings are suspected after tragic loss or severe injury occurs, it also sadly illustrates that a hospital Trust’s initial response to complaints about care may need further scrutiny.”
Sarah Richford, Harry’s mum said after the Trust admitted its guilt, “We've got some level of justice that means that although Harry's life was short, hopefully it's made a difference and that other babies won't die.”
National Influence - Harry's Grandfather Derek was nominated into the 2021 Heath Service Journal top 100 people who should be influencing the NHS. His family's campaign in Harry's name has had far reaching influence and he was nominated in the 20 "wildcards". https://www.hsj.co.uk/hsj100-the-wildcards/7030328.article
Derek Richford, grandfather and campaigner
Several people commented that NHS chief executives need to hear from harmed patients and families: Mr Richford has an extraordinary tale to tell of how his forensic attempts to find out why his grandson died a week after his traumatic birth led to the uncovering of massive failings in maternity services in East Kent. Regulators and commissioners seemed largely unaware of this, and it is only through Mr Richford’s efforts that there has been a court case and an ongoing independent investigation. The difficulty of getting to the truth was only matched by the grief suffered by his family.