Fundamentals of Harry's Story

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 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)

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.

So the Trust were fully appraised of the failings they were delivering 2 years before Harry, but failed to act, failed to learn.

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