Harry Richford: NHS Trust fined £ 761,000 for preventable baby death in landmark law enforcement

An NHS trust was fined £ 761,000 following a landmark CQC prosecution for failing to protect baby Harry Richford and mother Sarah Richford from avoidable mistakes that led to Harry’s death.

The East Kent Hospitals University Foundation Trust was fined in Folkestone Magistrates Court today after pleading guilty in April of failing to safely care for mother Sarah Richford and baby Harry Richford.

It is the first such prosecution by the Care Quality Commission that an NHS trust has failed to provide safe clinical care to patients.

Harry died in November 2017 of “totally preventable” mistakes made by staff at Queen Elizabeth The Queen Mother Hospital in Margate. He was delivered by caesarean section, but delays in breathing resulted in severe oxygen starvation and brain damage.

A coroner ruled the mistakes amounted to neglect by the Trust, which had failed to respond to previous security warnings that could have helped prevent the tragedy.

The Trust is now facing a winder investigation by Dr. Bill Kirkup faced nearly 200 cases of motherhood, including the deaths of other mothers and babies and children with severe brain damage. The police are also considering a criminal investigation into the lack of obstetrics.

In a statement to the court, Harry’s mother Sarah said, “There is no way I can really capture the pain and anger I experienced after what happened to Harry when he was born.

“I never thought I’d be so helpless, exhausted and desperate on an operating table, listening to a room full of panicked people whom I could rely on to deliver Harry safely.”

She said the poor care she and Harry received was “inexcusable”.

District Judge Justin Barron said it was “a really powerful, moving report” of what happened.

Said the goal of his ruling is to “bring home” the confidence it needs to change, adding, “Practices and procedures need to be put in place to ensure that what happened to you is not to anyone else happens. ”

There are clear “system failures,” he said, adding, “I have no problem figuring out that this is a case of high guilt” and “highest category of damage,” he said.

“It did the most damage imaginable.”

He said it was clear that no lessons had been learned from reports from the Royal College of Obstetricians after Harry’s death and that the family would have to fight to get answers.

He said the foundation will take action now, including hiring seven counselors and more than a dozen senior midwives.

He set a starting point for his £ 1.1m fine, but said, “I have to take into account the fact that this is not a private company, it is the NHS serving the entire community that will not be.” reimbursed by the government. And if the fine I’m imposing is a swing, it has a direct impact on patient care, and that’s not my goal as a judge. “

The fine was reduced by a third as the Trust found guilty prematurely, resulting in a fine of £ 733,000 plus a cost of £ 28,000 and a sacrificial surcharge of £ 170 for a total of £ 761,170.

The court heard that the trust had failed to contact the registrar, Doctor Dr. Christos Spyroulis, before he could work shifts in the maternity ward. He has not gone through an induction process and his skills have not been assessed. The court was told that Dr. Spyroulis was also poorly supervised by senior physicians.

Philip Cave, director of finance and performance, was asked to read a statement to the court on behalf of the trust and instructed by the judge to read it directly to Harry’s parents, who were in court.

He said the trust has insight into the mistakes that led to Harry’s death, adding, “These two patient safety events were caused by a number of factors, including a failure to ensure the safety of Baby Harry and Ms. Richford , poor clinical leadership, poor governance, human error, clinical and medical errors, failure of oversight, system failure, and failure to improve practice.

“I understand that parents of loved ones don’t have to push for change, and that’s testament to their characters against the backdrop and unimaginable loss they’ve done with it. The board is determined to improve the quality of care and counseling for those who use and depend on their maternity services. “

The major shortcomings in trust and Harry’s treatment were exposed by his family, and in particular his grandfather, Derek Richford, who the CQC initially advised in 2018 that after a “comprehensive review, we do not believe there was a violation of regulation”.

In January 2020, The Independent announced that there had been dozens of baby deaths at the Trust.

Between 2014 and 2018 there were 68 deaths among children under 28 days, of which 54 died within the first seven days. There were 143 stillbirths with 138 oxygen starvation during their birth.

In a statement, Harry’s family said, “Mistakes happen every day and in a hospital it leads to death, we have accepted this over time. Learning from these mistakes is crucial and makes hospitals a better and safer place for everyone.

“Unfortunately, both individual and systemic errors have been suppressed for many years without anything being learned. This failure to learn has led to the significant mistakes made in Harry’s death, and undoubtedly countless others, now identified by Dr. Bill Kirkup and his team are under investigation in the East Kent Maternity Inquiry. If these deficiencies had been corrected promptly and effectively, we would not be here today; we’re not here because of one evening’s mistakes. “

They added: “While we are glad that a sanction was imposed, we are not sure if the current system is suitable for publicly funded organizations such as NHS trusts.

“Taking money away from a financially troubled resource seems counter-intuitive and we would encourage policymakers to consider alternative options. This is not a criticism of the CQC or Judge Barron’s decision, which is constrained by the current guidelines. “

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