The Investigation

Within an hour or two of Harry's birth, two consultants, one Paediatric and one Obstetric told us there would be an investigation called a Root Cause Analysis (RCA) to find out what had happened.  The day after Harry died, November 10th, Sarah and Tom asked the consultant in charge of Harry's care at William Harvey Hospital whether Harry's death would be reported to the coroner, they were told no, there was no requirement as the cause of death was known. Subsequently the Trust were asked several more times but they refused including in writing.

We were deeply uneasy as the RCA was being conducted by Dr Clare Redfearn who was the consultant in charge of the maternity ward and was effectively investigating here own staff, colleagues and policies.  It later transpired that Dr Redfearn had only become a consultant a 2 months before Harry's death and that this was her first and only RCA. We raised our concerns with the Trust but they were dismissed.

We reported the whole of Harry's story as we knew it to the Care Quality Commission (CQC) and although we had acknowledgement emails there was  nothing more at this stage and they didn't seem very interested.  We also advised our MP Roger Gale who was really helpful and supportive but wanted to let due process happen first, which was of course fair.

The RCA seemed to take forever, we had sporadic updates but no one would tell us what was going on.  The RCA 60 day deadline was then extended to 90 days as the case was said to be "very complex"  On March 6th 2018 we were finally sent the RCA in hard copy only and an invitation to go and talk about the report at 2.00 pm on March 14th, we duly accepted and spent the time in between, day and night, poring over the 67 page report.  At first sight it seemed thorough enough, but when read in detail it threw up an awful lot of questions.

We arrived at the Trust in good time on 14th and at 2.00 pm were taken to a room, it wasn't ready and we helped them to arrange chairs and tables for everyone to sit on.  There were 5 of us and there was due to be 6 members of the Trust team including 4 consultants, Dr Clare Redfearn, Dr Anastasia Goumenou, Dr Abigail Price and Dr Sean Mun, a corporate governance officer Annie Oakley and a midwife coordinator Karen Keatley; this was a very big meeting.  One of the consultants turned up 10 minutes late and another was still at William Harvey Hospital and eventually arrived an hour late, we started without him.

The meeting was recorded at our request. The meeting was so poorly chaired, consultants were arguing with each other and at one point the consultant in charge of the RCA had to leave the room to compose herself as she was sobbing.  We asked a good number of searching questions regarding who signed off the locum doctor but they had no answers, all they could say was his CV was signed off by a consultant.  Around a month later we discovered that he hadn't been signed off by anyone at all, in fact, he had not been assessed by the Trust themselves in any way.   We asked again about calling the coroner and were told very definitely by Dr Mun and Dr Price, in fact for 12 full minutes, that referral was not required, it was stated by Dr Mun, consultant neonatologist "any Neonatologist in the country and they will tell you the same".  We pushed hard and and they eventually agreed to inform the coroner. We asked a lot more questions and we left the meeting after three and a half hours having far more questions than when we arrived.

It was from this point that we all knew what we had suspected for a long time, Harry's birth and what had surrounded it had seemingly been covered up and we were determined to discover the truth.

Soon after the meeting we received a list of questions that we had posed and also questions that had been raised by the local Clinical Commissioning Group (CCG) in the form of a grid.  There were numerous unanswered questions but at that time the Trust were promising answers.

The day after our March 14th meeting, we were so disillusioned by what we had seen and heard that we reported Harry's death to the coroner ourselves , we added a note to say that the Trust had also promised to report it, but that we had little faith they would actually do so.  We were right, we had to chase the Medical Director twice who eventually said if it hadn't been done, he would do it himself.  It wasn't until April 20th that the Trust finally reported Harry's death to the coroner over 5 weeks after they had promised to do so.

We had heard about the Healthcare Safety Investigation Branch (HSIB) and we sent the details of Harry's case to them.  Harry was born too early for their new maternity investigations so we had to make a very good case indeed.  Following a raft of emails, telephone calls and us giving enough evidence to them to persuade them that there was national learning to come from Harry's case, they agreed to take Harry's case on as a national investigation.  They started their investigation in late May 2018.

Following on from our March 14th meeting and the subsequent questions grid created by the Trust they agreed to have Harry and Sarah's notes looked at by Dartford and Gravesham Trust so that independent eyes could be cast across them. This had already been done by Maidstone and Tunbridge Wells Trust but in their report they complained of not being sent any hospital patient records or scans, only the RCA report written by the Trust.  The report from Dr Mark Waterstone at Dartford and Gravesham came back and was critical of many aspects of the care given and the interpretation of CTG scans, it also indicated that had Harry been resuscitated effectively he may have survived intact.  What surprised us and we believe the Trust too was the final comment "There appears to have been inadequate neonatal resuscitation which requires the expertise of a Neonatologist to review with authority."    We sent this report to the coroner to add to the evidence we had already provided into Sarah and Harry's care.

We immediately asked the Trust to get the neonatology report done too and, to be fair, they had realised that we would need this and had already set this in motion again via Dartford and Gravesham.

At 13.36 on Saturday 21st of July 2018 we received an email from the Medical Director. "The independent neonatologist has completed his review and I promised to share this with you. I'm really sorry because this will be extremely upsetting for you as a family to read and again I apologise for what we as an organisation have subjected your family to over the last several months."  The enclosed report from Dr Bokhari was devastating.  It described a largely chaotic resuscitation where records and timings were not kept and the expert said "I would recommend a significant review of the abilities of the staff in hospital to establish and maintain an airway of a newborn baby including midwives, Neonatal nurses and all junior doctors." This was devastating
news, despite all of what Harry had been through, he could have survived if the resuscitation had been carried out competently.  This report was also sent to the coroner.

We were invited to a Pre-Inquest Review on November 6th 2018.  The coroner went through witnesses required and Interested Persons (IP's) and asked for submissions regarding Article 2 of the European Convention on Human Rights - Right to life.  We argued for Article 2 as it would have significant implications for the conclusions of the inquest and the recommendations the Coroner could make about the failings of the Trust. The Trust argued strongly against it.  The coroner was persuaded by the Trusts arguments not ours so Article 2 was ruled out but the coroner said he would keep an open mind if any evidence changed.  Harry's inquest was due to be held at the end of February/beginning of March 2019. Both the paediatric and Obstetric Registrar's were made into IP's (Interested Persons) by the coroner’s court. 

We also reported these doctors to the GMC for investigation into malpractice.  They started with the Locum Obstetric Registrar who had carried out Sarah's Caesarean section.  After many months they found him guilty of malpractice and put 13 undertakings against his name. The summary of the decision in full is here

We decided there was evidence of deficiencies in the following areas of clinical performance; recognising and working within the limits of his competence; relationships with patients; record keeping; assessment and clinical management of patients; and operative/technical skills. In reaching this conclusion we took into account concerns raised in a complaint, information provided by Dr Spyroulis’ NHS body and the opinion of an appropriate expert.

The paediatric Registrar as well as the Obstetric consultant are also being investigated by the GMC for malpractice. 

In the background HSIB were still carrying out their investigation; we were also looking at just about anything we could get our hands on.  We found that on the Trust's website there were a complete set of board meeting actions and Integrated Performance Reports (IPR) which we downloaded and examined in detail, mainly through searching for "maternity" or similar key words.

After an awful lot of work trawling through reports and the internet, it became apparent that back in June 2016 the Trust had raised a Corporate Risk Register entry CRR26 that described "Regulatory non compliance in Obstetrics and Maternity" It described the cause as "Reports from both the Royal College of Obstetrics and Gynaecologists (RCOG) and the Local Supervisory Authority (LSA) identified gaps in regulatory compliance and also other areas of improvement in maternity services." it went on to describe the Inherent Risk Score as "Extreme".  The risk was due to be mitigated by 31st October 2016.  

We spent time and energy looking at as many board reports and IPR's as we could get, we downloaded them all and pored over them.  It emerged that the Trust had not completed the risk by October 31st.  In fact by February 2017 they reported that there were difficulties so they brought in another entry called CRR48.  We were spellbound by what we were discovering.  CRR48 had a new start date but the same wording, by April 2017 a report noted that CRR48 had subsumed CRR26 as they were basically the same thing.  Various dates for completion came and went but at no point all the way up to April 2019 was the risk seen as mitigated and complete.

We notified the coroner and the CQC of our new findings. 

The CQC local inspector wrote back to say that she had taken advice from senior management and that there was nothing for the CQC to look at as it centred around individual error.  We wrote back thanking her for her consideration but pointed out clear systemic issues and hoped she didn't mind, but I had copied in the head of hospital inspections Professor Ted Baker as I felt further senior opinion was required.  A week or two later we got a response from Professor Baker thanking us for the information and saying that their Inspection Manager for the South East would be in touch to arrange a meeting.

We looked at everything we could find online using Google to look for the nuggets of information we knew would be out there somewhere.  It seemed that the Trust had issues in maternity as far back as at least the end of 2013.  Local CCG reports told us that the number and themes of serious incidents had prompted talks with the Trust and NHS England (NHSE).  This led to a risk summit and then the RCOG coming into the Trust to carry out a full audit which prompted the risk entry.  

The risk register prompted us to ask for a copy of the RCOG report that had led to the risk entry CRR26 and so raised a FOI to get a copy.  After around 4 weeks the response came through from their FOI office with a link to the report which we downloaded.   The report had been researched by 5 RCOG assessors in November 2015, 2 years before Harry was born. 

This was the introduction to the report  published in February 2016, researched in November 2015. It clearly shows that there were already serious concerns running up to the commissioning of the audit.

INTRODUCTION
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.

You can download the RCOG report HERE

It gave various examples of issues that they found; Escalation, CTG misinterpretation, induction and for us, key, consultants were found not to be attending ward rounds and that this was being tolerated by senior management.  Towards the end of the report it said that the assessors were leaving after being assured that consultant attendance on ward would be monitored.  It talked of finding where consultants didn't attend ward rounds, this was not raised in RCA investigations, this concerned us greatly that consultants behaviour was being hidden. .  When talking about trainees and the lack of engagement from consultants, it said “The assessors are concerned that this practice will result in consultants not committed to teaching and supervision to be on-call with a locum middle grade doctor, potentially of unknown competence, which could impact on the safety of care in the maternity unit”  This was exactly what happened in Harry's case, it was an exact prediction of what Sarah, Tom and Harry had been the victim of. 

The result of the RCOG report was a Corporate Risk Register entry at the Trust to say that there was an "Extreme Risk" to pregnant women and Neonates in our care" this was in place from June 2016 and due to be mitigated by October 2016 but it wasn't - the last time it could be seen in a board report the end date had been extended to March 31st 2020.

We discussed what we had found within the family and concluded that there was strong evidence that Trust had known all about the serious issues at the Trust for a very long time and, had they addressed them, Harry would have had a normal birth and been alive and well.

We had a meeting arranged for the end of January 2019 with the CQC in London.  We presented a document that highlighted all of the issues we knew and also presented the RCOG report from 2015 which they were seemingly unaware of, we left a copy with them.  Here is what we presented.  They promised to investigate at the highest level and to take the maximum action they could thereafter.  It wasn't until late August that we heard that Harry's case had been in front of an internal panel and had been approved for 2nd stage investigation.  At this stage it looked quite likely that they were investigating a criminal case under Regulation 12 of the Health and Social Care Act 2008. Confirmation didn't come until October when they wrote to the Trust and us to say they were formally investigating a Criminal charge under Regulation 12 of the Health and Social Care Act.

Soon after our meeting with the CQC, the HSIB report was published.  Although HSIB are a no blame organisation who investigate in order to learn, they found 18 serious findings surrounding Harry's death. Details of the HSIB investigation are here 

We came to learn about a report that has to be filled out for government called MBRRACE-UK which logs all baby and maternal deaths and babies who sustain brain damage in order to try and learn why the UK is so poor with baby deaths.  We requested Harry's report on a FOI but were told that it was not a FOI matter as it will be in the clinical records of the patient.  Our request was sent to the clinical records department but we were told the report was not there, we asked several times.......  Eventually we got the report direct from MBRRACE-UK on Oxford under a FOI request.  When we got the report, we found it was full of wild inaccuracies. Such things as was the placenta kept was answered yes and then went on to say it was used for histology to determine the cause of death, the placenta was not kept at all. It said that the coroner had been called, he hadn't, rotational forceps were used, they weren't.  They said that the Apgar score at 1 minute and 5 minutes was not available, they were in Harry's notes.  The final part, were there any delivery complications was answered with None. We wrote to the Medical Director to ask where the information comes from for the  MBRRACE report and we were told "the patients notes" but Harry and Sarah's notes showed this to be untrue.

By the end of June 2019 we had a full and frank admission from the Trust's solicitors. “We have also carried out our own investigations, as a result of which the Trust accepts that the standard of care for your client, Mrs Richford and Harry, did not meet a reasonable standard, both during delivery and immediately afterwards.”  The admission was so stark and unequivocal that we felt vindicated in all our investigating, whilst being disappointed that
the wording suggested that only after the solicitors own investigation did the Trust accept what it had done was wrong.  This was exacerbated a week later when we got an apology from the CEO apologising that their care had "contributed" to Harry's death.  It went on to say that
there was an HSIB investigation being carried out and they would comply with its findings.  The HSIB report had been published to them in February, 4
months earlier yet the CEO seemed to have no clue whatsoever.  She later admitted to the BBC that she hadn't even seen the RCOG report until December 2019, just a month before Harry's inquest and nearly 4 years after it was published.

On the first day of Harry's inquest an apology was issued to the media.  This apology was a far stronger apology than anything we had received from them but still, they did not apologise for Sarah's care, only Harry.  The coroner was highly critical that neither he or the family were sent this apology.

The downside of an admission from the Trust is that our Conditional Fee Arrangement (CFA or "no win no fee") deal with our solicitor in Whitstable meant he could no longer come to the inquest or any PIR's as the Trust wouldn't have to pay him.  He wrote to the Trust to ask if they would pay for reasonable cover for the family as the Trust would be using public funds to represent themselves, but they refused.  We wrote to AvMA who are a really helpful charity but Harry's case was likely, at that stage to be a 10 day inquest and they couldn't get that much help from one barrister.  Our MP, Sir Roger Gale came straight to the rescue and endorsed an application to "Advocate" the Bar Council Pro Bono unit. 

Within a couple of weeks we had cover from a top barristers chambers in London.  Brick Court Chambers who were supported by solicitors Arnold and Porter LLP, one of the biggest law firms in the world. We were very fortunate indeed and will forever be indebted to Jenny, Emma, Jackie, Louise ,Giles and Daisy for their care, professionalism and the genuine love they showed our family.

We kept sending evidence to the coroner and the CQC in order to keep them abreast of matters and to try and push the coroner into finding us a date.  At one point we were told that the inquest was now likely to be September/October only to be told soon after that early 2020 was now more likely.  The anguish that this all caused cannot be underestimated.   At last, at the beginning of August we got a date for a 2nd PIR, this was to be a full day event on October 16th 2019, at least we had some progress.

Two weeks after being told the new PIR was on October 16th we were told that our coroner had double booked with another inquest and could not now conduct Harry's inquest. We emailed our MP again, he had been really helpful with sending emails and supporting us in every regard, he had recognised that Harry's case was one of importance not only to us but the wider community.  He wrote to the Chief Coroner to gently ask if anything could be done to expedite Harry's case, inevitably the response came back to say that he couldn't deal with any individual cases.

By early September we were called to an urgent PIR with a new coroner, ours had retired as he was 70 and we got a very experienced barrister coroner who certainly seemed to know his stuff, he was Christopher Sutton-Mattocks. He was a semi-retired barrister and had a great deal of experience in Article 2.  At the urgent PIR he asked for submissions on Article 2 again, IP's and witnesses.

A full day PIR was called for October 14th in Sandwich Kent and Harry's inquest was set for January 6th for 2 weeks and 2 days. Various papers were requested including policies and procedures in force when Harry died and a full statement from the Medical Director.  In what can only be described as deep disrespect for the family, the Trust failed to supply this paperwork before the inquest but on day 2 of the inquest dropped over 1,000 pages on our legal team. The Medical Directors statement, one of the most important statements was supplied on New Year's Eve 2019 just 2 working days before the inquest.

As a result of Harry's death two registrars and a consultant involved in Harry's delivery have been before the GMC regarding fitness to practise.

It wasn't until December 13th that we were sent the Coroner's expert report on midwifery. It was another devastating read and showed that CTG's had been misinterpreted by different midwives and that Syntocinon had been overdosed.  All in all, the report showed that, in the words of the expert, care fell below or well below the expected standard.  The NMC are now investigating 7 midwives.  

We therefore had three coroner’s experts telling us and the court that the midwives, obstetricians and paediatricians all offered Sarah and Harry substandard care.  We were left wondering how all this could happen in one place at one time unless gross systemic failings were to blame