'Wholly avoidable' death of week-old baby was result of hospital failures, inquest rules

  • Video report by ITV News Correspondent Angus Walker

The death of a baby just seven days after he was born was "wholly avoidable", a coroner has concluded.

Harry Richford was born by emergency Caesarean section at the Queen Elizabeth the Queen Mother Hospital in Margate on November 2, 2017.

The "much-desired and much-loved baby" died a week later.

Coroner Christopher Sutton-Mattocks said on Friday he found a number of errors with the care given to Harry and his mother Sarah Richford and found neglect contributed to Harry's death.

"They are grieving for a child they believe should not have died... I agree with them," he said.

Speaking outside court, Harry's parents Sarah and Tom called on the Home Secretary Priti Pratel to investigate the NHS trust managing the hospital, citing "frightening" similarities between Harry's death and the deaths of other babies reportedly under their care.

"Accidents happen every day, but failing to learn from them appears to have become a part of the culture of this NHS trust," Tom Richford said.

"I hope this case can be a turning point to ensure that this does not happen to anybody else going forwards."

  • Harry's parents, Sarah and Tom, giving a statement outside court.

Medical Director Dr Paul Stevens from the East Kent Hospitals University NHS Foundation Trust, which runs the Margate hospital, apologised over Harry's death.

"We are deeply sorry and wholeheartedly apologise... (we) accept the coroner's conclusion and findings," he said.

The trust also confirmed at least seven preventable baby deaths may have occurred in their hospitals since 2016.

The Care Quality Commission (CQC) confirmed on Friday it was currently investigating the trust over alleged malpractice but said no decision to prosecute had been taken "at this stage."

The hospital has apologised and accepted the coroner's findings. Credit: ITV

Handing down his conclusion at County Hall in Maidstone on Friday, Mr Sutton-Mattocks found there was an inexperienced doctor in charge of the birth, and there was a failure to request support from a consultant earlier.

"Mr and Mrs Richford were failed by the hospital, but more importantly, Harry was failed," the coroner said.

He said an expert had advised Harry should have been delivered within 30 minutes at 2am, but instead he was delivered 92 minutes later at 3.32am by Dr Christos Spyroulis.

East Kent Hospitals University NHS Foundation Trust admitted it has "not always provided the right standard of care," in its maternity services.

A nurse described the scene as Credit: ITV

Harry's parents had pushed for a judgement of unlawful killing, but the coroner concluded the hospital's failings were not "so large" to fall in this category.

Mr Sutton-Mattocks criticised the hospital's decision to give Mrs Richard a drug to speed up labour when she arrived at hospital, saying it 'hyper-stimulated' Harry.

She was rushed to the theatre as Harry began to show signs of distress, where medics attempted to deliver with forceps before decided on an emergency section.

Mr Sutton-Mattocks said a staff nurse who had been called to help with Harry's delivery, Laura Guest, described the scene as "chaotic" and added that she "didn't feel it was being strongly led".

The Trust runs five hospitals and community clinics and serves a population of about 700,000 people. Credit: ITV

He said the situation must have been "terrifying" for Mrs Richford, as there were between 20 and 25 people in the theatre.

The coroner said resuscitation began after Harry was born "silent and floppy" and not moving.

He praised anaesthetist Dr Dhir Gurung who stepped in to intubate Harry, crediting the action with giving seven days to spend with his family.

The East Kent Hospitals University NHS Foundation Trust is one of the largest in England, running five hospitals and community clinics and serving a population of close to 700,000 people.