The Inquest
From Tom Richford's statement to the coroner -
"I’m not just one voice, I am the voice for all those who have suffered at the hands of the Trust and their inadequate maternity department. We respectfully ask the Coroner to consider the fact that it is the family’s real wish to seek justice for all of those that have been in this position."
Harry's was an Article 2 inquest based on the European Convention on Human Rights - Right to life described as -
"Article 2 inquests are enhanced inquests held in cases where the State or 'its agents' have 'failed to protect the deceased against a human threat or other risk' or where there has been a death in custody"
We had asked time and time again for the Trust to report Harry's death to the coroner but they refused. Eventually after 4 and a half months and several meetings the family reported Harry's death to the coroner themselves on March 15th 2018 (letter Here) but very little happened for quite some time.
The Trust had promised to report his death following pressure from us in a meeting on March 14th however, the Trust didn't report it until April 20th 2018 some 5 and a half weeks later . It wasn't until much later that we discovered that the coroner was not allowed to carry out an inquest on Harry without permission from the Chief Coroner of England as there was no longer a body. It wasn't until the end of August 2018 that we got a call from the coroner’s office to say that an inquest into Harry's death was to be held.
Harry's inquest was opened and adjourned on September 3rd 2018. We were notified of a Pre-Inquest Review (PIR) which was to be held on November 6th and we duly attended. It only lasted an hour but it laid out the various procedures and asked what Interested Persons (IP's) should be sought and also witnesses. The coroner had said that he was minded that Harry's case could come under the European Convention of Human Rights Act, Article 2 type inquest, and invited submissions on this. By the time we left we had 21 witnesses being called, 6 being read and two registrars as IP's.
Two weeks later the coroner wrote to say that he had considered submissions on Article 2 and was persuaded by the Trust's arguments that Harry's case was not Article 2 at that time. However, he would keep an open mind as and when more evidence became apparent. He indicated that Harry's inquest would likely be at the end of February beginning of March 2019.
The weeks came and went. We chased the coroner’s office regularly and they eventually said that the inquest would be delayed as the HSIB report had taken longer than they had anticipated. Around April 2019 the coroner appointed two expert witnesses to report on Obstetrics and Neonatology. It was at around this time we were asked if we could attend an inquest sometime between 16th July and 3rd August, we readily agreed, at last, light at the end of the tunnel.
The expected inquest date was changed again to September/October and a month later we were informed that it was now likely that it would be early 2020. The pressure of all of the waiting cannot be overstated and weighed heavy on the entire family.
By early August we were told of a full day PIR on October 16th, but two weeks later this was rescinded. By early September we were called to an urgent PIR with a new coroner, Christopher Sutton-Mattocks, our original coroner had apparently retired, as he was 70 and we got a very experienced barrister coroner who certainly seemed to know his stuff. 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 once more as well as 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. The coroner also felt that the on-call consultant Anastasia Goumenou should also be an IP in Harry's case.
On October 1st 2019 the CQC wrote to the Trust advising them that they were now investigating a criminal charge under regulation 12 of the Health and Social Care Act 2008 - Safe Care. The letter sent is here.
On October 18th the coroner published his ruling on Article 2. He ruled that Harry's inquest now passed the threshold for an Article 2 inquest and it was to be heard as such. Full ruling HERE
“This inquest does in my judgement pass the threshold, for all the reasons I have set out above in paragraphs 15 onwards, for being an exceptional case in which the cumulative factors fall within identified systems or structural failings. They are in my judgement so substantial that it is at least arguable that the systemic failures were so severe that the threshold set out in paragraphs 88 and 89 in Parkinson is passed. In my judgement it is at least arguable that the cumulative systemic or structural failings in this case can be linked to the harm sustained by Harry.”
So Harry's case, that the Trust did not even want the coroner to know of, was now to be an Article 2 inquest, the highest level of inquest available in the UK. If this didn't prove that the Trust had failed in their duty to report, what would?
The inquest went ahead on January 6th and, in the end lasted a full 3 weeks which included a small delay due to a contempt of court issue by the Trusts obstetric consultant, the same one who failed to turn up for ward rounds and overnight when required.
During the inquest the Medical Director's statement included the following -
"The analysis of the root cause of Harry Richford’s death led to actions similar to some of those in the RCOG review, CQC reports of 2014-2016 and the HSIB recommendations, indicating a failure to sufficiently embed learning." and later in the same statement "A specific question has been asked with respect to referral to the Coroner. I met with the senior coroner at the end of August 2018 and discussed this. Her view was that, notwithstanding the diagnosis of hypoxic ischaemic encephalopathy, failure to refer may constitute obstructing the coroner."
In a letter from Susan Acott CEO to Sarah and Tom dated March 14th 2019, she stated "Dr Stevens met with the coroner to discuss Harry's case and whether referral should have been made earlier, and if so, whether the guidelines from the coroner were clear enough. This concluded that the coroner would have welcomed an earlier referral; that she would want to see all neonatal deaths referred in the future, and that Dr Stevens would discuss this view and Dr Mun's judgement with Dr Mun to ensure he was clear regarding the requirements."
From that day in August 2018 the Trust were ordered to report all baby deaths to the coroner. However, at Harry's inquest some 18 months later it was revealed by consultant Dr Sean Mun that if deaths were considered by medics to be from a "congenital defect" they had not been reported................
To us this emphasised the historic issues and proved that learning had not taken place sufficiently. As a post script, the CQC when they inspected the Trust whilst Harry's inquest was taking place, found much the same issues and this led to a full independent inquiry, the Kirkup Inquiry. The inspections of both QEQM and WHH were both published on May 28th 2020 and on the very last pages of each showed, for QEQM a legal breach of safe care and for WHH the same legal breach as well as a legal breach of governance. So even in January 2020 the Trust were failing badly in maternity.
In his statement to the inquest, the Medical Director made a number of claims of improvements already made by the Trust, these included "Increase in midwife to birth ratio from 1:32 to 1:28" but later examination showed that 1:28 had always been the target and largely achieved. He also claimed "The Birthing Excellence Success Through Teamwork (BESTT) programme launched in November 2017" the same month Harry was born. However, the Truth was that the scheme had been launched 6 months earlier in May but had clearly failed to be effective.
In the last few days of the inquest the coroner asked the legal teams to submit legal arguments on possible conclusions. Our team put forward "Unlawful Killing" as a first option and "Neglect" as a second. The Trust, via their solicitors Clyde and Co astonishingly put forward "Accident", even after nearly 3 weeks of inquest it seems the Trust did not accept their failings at all, in our eyes they just didn't "get it" and we wondered if they ever would.
On Friday 24th January 2020 the coroner gave his conclusion -
He initially read a long statement that included the following paragraph that brought the entire court to tears -
3/ The poet John Donne wrote “any man’s death diminishes me”....if that is true how much more are we all diminished by the death of a new born baby. Today Harry should be almost 2 years and 3 months old. He should be a bundle of energy causing no end of mischief as a happy active young child. Instead his family are grieving, and will no doubt for the rest of their lives. What makes it worse is that they are grieving for a child they do not believe should have died. I agree with them. Harry’s death was in my judgement wholly avoidable. Mr and Mrs Richford were failed by the hospital, but more importantly Harry was failed.........
The full conclusion as read aloud by the coroner can be found here, please note hand written parts are by the coroner.
Coroners Ruling 24th January 2020
I Find there were the following failures in the case of Harry Richford-
a) He was hyperstimulated by an excessive use of Syntocinon over a period of approximately 10 hours.
b) Once the CTG reading had become pathological by 2.00am Harry should have been delivered within 30 minutes and not 92 minutes later.
c) The delivery itself was a difficult one. It should have been carried out by the consultant who should have attended considerably earlier than she did.
d) The locum on duty that night was relatively inexperienced. He was not properly assessed, if at all and should not have been put in the position of being in charge unsupervised.
e) There was a failure to secure an airway and achieve effective ventilation during the resuscitation attempts after birth leading to a prolonged period of postnatal hypoxia. The resuscitation afforded to Harry Richford failed to be of an appropriate standard.
f) There was a failure in not requesting the consultant support earlier enough during the resuscitation attempts.
g) There was a failure to keep proper account of the time elapsing during the resuscitation attempts with the effect that control was lost.
Harry Richford’s death was contributed to by neglect.
CJ Sutton-Mattocks
Assistant Coroner for the county of Kent
Prevention of Future Deaths (PFD)
On February 7th 2020 the coroner released his Prevention of Future Deaths Report (PFD) regarding Harry's death. There were a staggering 19 concerns all with individual recommendations in order to prevent future deaths. You can download the report here Research into PFD's has been unable to find any inquest with as many recommendations in any setting anywhere in the UK.
So many of the recommendations had very similar themes to those raised by RCOG in their 2015 audit. It felt gut wrenching that over 4 years later the coroner needed to raise the same issues. Remember, every one of the 19 recommendations are individually there to "Prevent Future Deaths" Had the Trust dealt with the RCOG recommendations, we are convinced that our Harry would not have died.
After the inquest, the Senior Coroner for Kent, Patricia Harding 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." She went on to say -
"In my experience the practice that is universally followed (although sadly not it would appear in this case) is for the doctors to refer deaths directly to the Coroner where appropriate and not rely on the Registrars to refer the death themselves."
Sir Roger Gale MP said after the inquest -
“I would like to commend the courage and quiet dignity with which my young constituents, Tom and Sarah Richford, have conducted themselves since the death of their infant son, Harry, and throughout the process since.
“I have been engaged in this sad case since the family approached me following their loss and it is immediately apparent that their only concern has been to seek to ensure that no other young family has to suffer as they have done. To lose a child is terrible. To know that that loss could and should have been prevented adds immeasurably to the pain.
“I would like to express my thanks to the barristers and solicitors who have given their services tirelessly and without charge to seek to ensure that my constituents have been fully and properly represented.
“Lawyers are frequently criticised but through Advocate (The Bar Pro Bono Unit) the Richford family has received superb legal support. They have not just `gone the extra mile`: they have, I am advised, run a marathon to secure the truth.
“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."
“Many changes have already been made as a result of this case and more must follow. I have discussed the matter personally with the Secretary of State and Matt Hancock has assured me that there must be full transparency in further enquiries that will have to be undertaken and that every last lesson possible must be learned to prevent any repetition of this kind of tragedy and to restore full confidence in the maternity services within the East Kent hospitals trust.
“We owe that to the Richford family, to future mothers using the service and to a dedicated team of staff within maternity at the QEQM who wish to provide the best possible facilities and attention to those, mothers and babies, in their care. Harry Richford`s death cannot be allowed to have been in vain.”
On March 5th 2020 Kent County Council Registration Service re-issued Harry's death certificate to show the 7 serious failings and neglect that caused his death. A permanent record of the disgraceful acts and omissions that caused Harry's death.
Below is a selection of comments from expert witnesses and one from the coroner as examples of what was said.
