NHS Trust pleads guilty to failing to provide safe care to baby

NHS Trust pleads guilty over ‘wholly avoidable’ death of seven-day-old boy at scandal-hit hospital where doctors refused to work weekends

  • The NHS trust has pleaded guilty to failing to provide safe care and treatment 
  • Harry Richford died in November 2017, seven days after his emergency delivery 
  • Inquest found his death at Queen Elizabeth The Queen Mother Hospital in Margate was ‘wholly avoidable’

An NHS trust has today pleaded guilty to failing to provide safe care and treatment following the death of a baby boy, in the prosecution of its kind.

Harry Richford died seven days after his emergency delivery at the Queen Elizabeth the Queen Mother (QEQM) Hospital in Margate.  

An inquest later found that Harry’s death in November 2017 was ‘wholly avoidable’. 

At Folkestone Magistrates’ Court in Kent today, the East Kent Hospitals University NHS Foundation Trust admitted failing to provide safe care and treatment to Harry and his mother Sarah Richford.

Sarah and Tom Richford with their son Harry, who died seven days after he was born in November 2017

The maternity unit of the Queen Elizabeth the Queen Mother (QEQM) Hospital in Margate

The maternity unit of the Queen Elizabeth the Queen Mother (QEQM) Hospital in Margate 

What were the failings at East Kent NHS? 

The trust at the centre of a scandal over baby deaths failed to deliver Harry Richford on time, 92 minutes after an expert advised he should be.

Harry died at just seven days old after being delivered by C-section on November 2 last year. 

The QEQM also gave Mrs Richford a drug to speed up labour, which hyper-stimulated the infant. 

Archie Batten died on September 1  shortly after being born. His mother had called QEQM to say she was in labour.

But she was told the maternity unit was closed and to drive herself to the trust’s other hospital, Ashford’s William Harvey, 38 miles away.

Four midwives went to her home after the journey was deemed not feasible but they struggled to deliver the baby.

The mother was transferred by ambulance to QEQM, where her son died. His inquest in scheduled for March.   

Archie Powell died at four days old on February 14 after medics treated the twin for a bowel problem.

They failed to spot he had a common infection despite him showing all its symptoms and the delay in treatment sparked severe brain damage.

Tallulah-Rai Edwards was stillborn on January 28. Her mother had become anxious in the 36th week of pregnancy due to her baby’s slowed movement and went to hospital.

Despite struggling to get a good heart-rate reading on the cardiotocography (CTG) machine, midwives sent her home. The baby was found to have died two days later when her mother returned to the hospital.

Hallie-Rae Leek died aged four days old on April 7 2017. A midwife had struggled to find a heart-rate and she was born in a poor condition.

She was resuscitated after 22 minutes but the damage was irreparable.  

There were two stillbirths at the trust in 2016, in March and June. In the first case, the unit failed to recognise that an infant was small given the stage of development. They did not act on suspicious CTG readings and failed to deliver the baby promptly.

In the second case, the trust missed risk factors and failed to properly monitor a CTG and a baby girl died. 

At an inquest into Harry’s death last year, Coroner Christopher Sutton-Mattocks listed a series of errors he found with the care given.

He said that Harry should have been delivered within 30 minutes at 2am – but instead he was delivered at 3.32am, 92 minutes after an expert had advised he should have been delivered.

He also found that an inexperienced doctor was in charge of the birth, and that there was a failure to request support from a consultant earlier.

Harry’s mother Sarah Richford, a teacher, was considered to be ‘low-risk’ during her pregnancy.

She had been taken to theatre for an emergency Caesarean section on November 2, 2017. 

After arriving at hospital, Mrs Richford was given a drug to speed up labour over a period of 10 hours – a decision which was criticised by the coroner, because it hyper-stimulated Harry.

She was rushed to theatre after he began to show signs of distress, where medics tried to deliver with forceps before performing an emergency section.

Locum registrar Dr Christos Spyroulis, described by the coroner as ‘inexperienced’, delivered Harry at 3.32am.

It emerged in the inquest that there was no record of the doctor being assessed, and he had said that he was not asked about his level of experience.

The coroner said staff nurse Laura Guest, who had been called to help with the emergency delivery, had described the scene as ‘chaotic’, adding she ‘didn’t feel it was being strongly led’.

Resuscitation began after Harry was born ‘silent and floppy’ and not moving. 

Mr Sutton-Mattocks said the situation must have been ‘terrifying’ for Mrs Richford, as there were between 20 and 25 people in the theatre.

The inquest heard that if Harry had been resuscitated within ten to 15 minutes of birth, he would not have suffered the irreversible brain damage that killed him. 

Anaesthetist Dr Dhir Gurung stepped in after 28 minutes to intubate Harry, an action praised by the coroner, who said it gave the family seven days to spend with the baby.

Harry was then transferred to the intensive neonatal unit at William Harvey hospital, where he died on November 9.

Mr Richford said the East Kent Hospitals NHS Trust knew there was an ‘extreme risk to pregnant women and neonatals in their care’ at the time of Harry’s birth.

The trust pleaded guilty to failing to provide safe care and treatment under the Health and Social Care Act 2008 (Regulated Activities) Regulations.  

The Healthcare Safety Investigation Branch (HSIB) has been investigating East Kent Hospitals University NHS Foundation Trust since July 2018 following a series of baby deaths.

Harry's father Tom Richford (with wife Sarah) pictured outside court in January last year

Harry’s father Tom Richford (with wife Sarah) pictured outside court in January last year

An independent report published last April by the Department of Health and Social Care outlined 24 maternity investigations undertaken since July 2018, including the deaths of three babies and two mothers.

Dr Bill Kirkup, who led the investigation into serious maternity failings at University Hospitals of Morecambe Bay NHS Foundation Trust, has been appointed to carry out an independent review into East Kent Hospitals’ maternity services.

The first-of-its-kind prosecution comes after Harry’s parents Tom and Sarah Richford spent years fighting for answers and campaigning for better maternity safety.


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