The end of Harry's inquest on January 24th 2020 was the end of a chapter but not the end of his story by a long long way.
The Monday after the conclusion of Harry's inquest, Harry's name was mentioned 4 times in parliament, Roger Gale MP (North Thanet, Rosie Duffield MP (Canterbury). Natalie Elphicke MP (Dover) and by Craig McKinlay MP (South Thanet). The Health minister Nadine Dorries said that she had asked the CQC and HSIB to report on the Trusts Maternity services by February 10th, two weeks later. Details here House of commons 1 and House of Commons 2 and here is the Hansard account of the parliamentary urgent question HERE.
At the end of January the East Kent Clinical Commissioning Groups (CCG's) had their meeting that included a long assessment of the issues at EKHUFT maternity service. CCG Report This revealed that there had been input from the CCG, QSG and NHSE during 2018; it showed that in just 3 years, 2017-2019 there had been 27 serious incidents reported by the Trust and that reviews by the Child Death Overview Panel (CDOP) were now taking place. More concerning was this statement "The 2017 data shows that EKHUFT were a high outlier for neonatal deaths in their comparator group."
The CQC and HSIB reports were delivered on time and were damning, even at this late stage, 2 years after Harry's death, maternity services were unsafe. (HSIB report HERE). The government put in a task force said to be the best in the country to make it safe immediately. Sir Roger Gale told us that it was a very senior task force and it was a choice between that and shutting the maternity departments at the Trust down while measures were adopted.
Later in the week, on Thursday 13th February, the government announced a full independent inquiry that would be headed up by Dr Bill Kirkup; he was the same man who chaired the Morecombe Bay maternity scandal and on the Hillsborough Inquiry panel, he was probably the best man in the country to be appointed to this task. We were delighted.
By the end of that day, NHSE had written to Tom and Sarah asking them to meet with Bill in order to help set the terms of reference for the inquiry. The inquiry would take up to 2 years.
We were of course sure that Bill Kirkup would use the 19 recommendations from the coroners Prevention of Future Deaths Report as a starting point but we were also keen to add into the mix the cover up, the cover up that, without our intervention would have prevented learning in Harry's case. We felt such a cover up was very unlikely to be a "one-off" and therefore our contention was that previous cover ups may have stopped learning that could have saved Harry's life.
From January 2019 the CQC had taken far more interest and were fully investigating the circumstances of Harry's death. On 1st October 2019 the CQC formally told Susan Acott the Trust CEO that they were investigating a criminal charge into Harry's care and subsequent death.
"We have reviewed the circumstances of the death relating to Harry Richford, on 2 November 2017 at Queen Elizabeth The Queen Mother Hospital.
Following this review, the CQC has decided to begin a formal criminal investigation into the circumstances of this incident. We may request further information in relation to this incident."
We fully expected the CQC to make an announcement in March 2020 regarding the criminal prosecution, but the COVID-19 pandemic took hold. It would seem impossible to us that such a prosecution would not be taken forward as the evidence is exceptional and the care clearly unsafe. The announcement had to be made by November 1st due to a 3 year legal limit. (Update - Decision made to criminally prosecute October 9th 2020, see later). Here are the details of the CQC enforcement guidance that they were considering Harry's case against - https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-12-safe-care-treatment
Regulation 12 "unsafe care" is rarely used, here are the details of prosecutions made - CQC Criminal Prosecutions you will see that the CQC have never prosecuted for unsafe clinical care before.
In February 2020, the Nursing and Midwifery Council (NMC) Director of Fitness to Practice, Matthew McClellend issued a press release -
“The maternity safety issues at East Kent NHS Trust are deeply concerning for people using services and their families.
“As the professional regulator for midwifery and nursing professionals, we stand ready to play our part in the recently announced investigations in the interests of influencing the delivery of better, safer care that we all want to see.
“While we’re unable to discuss any potential or actual referrals involving individuals whose fitness to practise has been brought into question until they reach a public hearing stage, we are aware of concerns directly raised with us by one of the families involved which we’re reviewing further and remain in contact with them.
“In the meantime, we’re actively engaging with the Trust and working with our partners so that we can respond as necessary.”
In March, the Nursing and Midwifery Council (NMC) contacted us to say that as a result of looking at all of the files, in addition to 4 midwives already being investigated, they wanted to investigate a further 3 making 7 in total. The GMC had already disciplined the locum doctor and had decided to discipline the paediatric registrar but not decided to what extent and were still investigating the obstetric consultant. The Parliamentary and Health Service Ombudsman (PHSO) were investigating how the trust handled the complaint overall and were a good way into their findings.
By mid March we were all in the middle of the COVID-19 pandemic and the NHS were pulling out all the stops and working incredibly hard to save lives from this terrible disease. As a result, The NMC, CQC, GMC and PHSO all held back on investigations to allow trusts to get on with the day-to-day work that was so vital. They all promised to return to their investigations later in the year. As at October 2020 the NMC are investigating 7 midwives in Harry's case. The PHSO are awaiting Terms of Reference from the Kirkup team and the GMC are still investigating.
By Mid-March the Trust produced a dedicated part of their website to keep the community updated - https://www.ekhuft.nhs.uk/patients-and-visitors/news-centre/maternity-news/ The timeline on the left of that page is somewhat scant in detail especially the period between February 2016 and April 2018 following the RCOG report. It also fails to say that Susan Acott was appointed as interim CEO in October 2017, preferring only say when this was made into a substantive position 6 months later. The statement also says "It’s clear that for some time now the NHS has not provided all the people of East Kent with the high level of maternity care they need and deserve, and for this we are profoundly sorry." being that this is from the Board of Directors, rather than "NHS has not" it should surely have said "We have not" and taken some ownership?
By the end of March the Department of Health and East Kent Hospitals Trust responded to the Coroners PFD report, you can view the DoH response here and the response from the Trust here it will be important that the regulators keep an eye on these commitments.
On April 21st the Kirkup Inquiry started but due to the COVID-19 situation it received little media coverage other than Meridian TV - In time a request for further families with concerns would go out. Here is The Inquiry press release
On May 28th 2020 the CQC released its reports into QEQM and WHH maternity services derived from its inspections in January and February this year. Both reports showed that there were still some key safety issues regarding level and experience of doctors, escalation and the level of decisions made by midwives as well as a host of others. The CQC issued the Trust with formal statutory breach warnings requiring a response, as the Trust were not meeting their legal duties surrounding safe care and governance in maternity. You can read the reports that have been highlighted by us here - QEQM and WHH so that you can quickly see what concerns the CQC had. The last page on each document shows that both hospitals had legal breaches of safe care and treatment in January 2020, staggering when you consider all that had gone before.
The report was so concerning that the Royal College of Midwives CEO Gill Walton issued a press release on the same day that can be read in full here
It opens with -
“The RCM is disappointed to read this report and see the same issues that were flagged in the Royal College of Obstetricians and Gynaecologists invited review in 2015 remain. There is an urgent need for actions to be completed so safety is not compromised and this needs to happen at Board level within the Trust. Safety must be the absolute priority and the basis on which all care is delivered and on which all decisions are made. Good leadership at every level of maternity services is key to delivering safe, high-quality care for women and their babies."
Clearly the RCM wanted to make the point that in the 5 years between the RCOG audit and this latest CQC report, the same issues existed and that the Board of Directors needed to sit up and take notice which they had clearly failed to do before this time.
What is even more staggering was the discovery that on April 8th 2016, the Trust published the following in their Board report -
"Initial information from the recent Royal College of Obstetricians and Gynaecology Maternity Review report is clear – the Trust does not have an unsafe maternity service but there is improvement work to do around how the service is run in some areas."
Anyone who has read the RCOG report will testify that it had really serious concerns about safety at the Trust. It is clear that the Trust didn't accept the RCOG report even though they had commissioned it along with the CCG and NHSE, what utter arrogance and a gross dereliction of their duty this showed.
On July 13th 2020 the Trust published their Board Pack for the Board Meeting on July 16th. Within these papers the Learning and Review Committee (LRC) phase 1 report was published. It showed, following a review of the 2015 RCOG by Dr Des Holden (Medical Director of Surrey and Sussex NHS Trust) that of 23 recommendations ONLY 2 had been fully met 4 and a half years later. To us, this was gross negligence of the highest order.
"Of 23 recommendations the LRC accepted that two were met, 11 were partially met, and for 10 there was either no evidence of delivering the recommendation, or available evidence suggested it had not been delivered."
We believe that had the recommendations all been followed professionally and diligently Harry and countless others may not have died. BBC Story
In the same set of Board papers we were astonished to read a review of the CQC inspections of maternity services earlier in the year. These reports had shown that QEQM had been served a "requirement notice" for legal breaches in maternity under "safe care and treatment" and WHH , 2 "requirement notices" (Details Here) one for safe care and one for governance. Yet Susan Acott, CEO felt able to make this astonishingly positive comment -
"SAc stated the Care Quality Commission (CQC) report published following the unannounced inspections of the Trust’s maternity services in January and February 2020. This report provided a rating of ‘good’ for effectiveness, care and responsiveness, and ‘requires improvement’ for leadership and safety. She highlighted this was an improved rating from the previous CQC inspection.
It seemed incomprehensible that Susan Acott could highlight that this was an improved rating in maternity when the reports were clearly so damning and showed that QEQM had a legal breach of safe care and treatment in maternity and that WHH had two legal breaches in maternity, one for safe care and treatment and one for governance? The full board papers are here. Was this a case of wilful blindness?
As part of the RCOG report from November 2015, the RCOG were required to follow up the report to discuss outcomes and ensure recommendations had been actioned.
When we asked, the RCOG said (Copy Here) "The RCOG is extremely disappointed that the recommendations put forward by its report have not been implemented by East Kent Hospitals University NHS Foundation Trust." They went on to say that when the followed up the review they were first told that the Trust was preparing for a CQC inspection and on a second approach got no response at all. They went on to say "While the RCOG is not a regulatory body, and does not hold power to ensure action, it undertakes these invited reviews in good faith that the Trust will act upon them to ensure the safety of services.",
At the end of July, the governments Health and Social Care committee announced an inquiry into maternity safety which referenced the issues in East Kent which were triggered by Harry's case as well as those in Shrewsbury and Telford.
The Committee will build upon investigations that followed incidents at East Kent Hospitals University Trust and Shrewsbury and Telford Hospitals NHS Trust, as well as the inquiry into the University Hospitals of Morecambe Bay NHS Trust.
We have made our comments to the committee and have separately been invited to speak with Nadine Dorries the Health minister in charge of patient safety.
On October 9th 2020 the CQC announced that they would be criminally prosecuting East Kent Hospitals Trust on two counts for unsafe care and treatment one for Harry and one for his mother Sarah. This was a landmark decision as no NHS Trust has ever been prosecuted for unsafe clinical care ever before in the UK. The family were pleased with the decision and especially pleased that Sarah's poor care had also been recognised. It is expected to come before magistrates around April of 2021. https://www.bbc.co.uk/news/uk-england-kent-54468137 https://www.dailymail.co.uk/news/article-8822985/NHS-trust-East-Kent-Hospitals-charged-babys-death.html
On December 10th 2020 Donna Ockenden published her interim report into baby deaths at Shrewsbury and Telford Hospital Trust (SaTH). The report was damning and showed that there were failings of consultant presence, lack of escalation, misuse of Syntocinon, failings in midwifery and fundamentally a failure to learn. The exact same failings befell Harry and Sarah in November 2017 in East Kent.
On March 11th 2021, the Kirkup Inquiry Terms of Reference were laid before parliament, they are comprehensive and we look forward to the conclusions in Autumn 2022. Terms of Reference here
The criminal prosecution went before District Judge Barron on Monday 19th April and the Trust entered a plea of Guilty on both counts for unsafe care and treatment for Sarah and Harry, sentencing will follow on June 18th.
We will add more here as and when there are other significant updates.