NHS Trust to be prosecuted for “wholly avoidable” death of newborn baby
The Care Quality Commission (CQC) will prosecute an NHS Trust in relation to two charges over the death of baby Harry Richford, who died at only seven days old in November 2017. This is the first time an NHS Trust has ever been prosecuted in relation to unsafe care.
An inquest before Her Majesty’s Assistant Coroner Christopher Sutton-Mattocks, concluded in January 2020, found that his death was “wholly avoidable” and was contributed to by neglect. The Trust have been charged with two criminal offences: failing to provide safe care, exposing both Harry and his mother to “significant risk of avoidable harm”.
The background to Harry’s death
Sarah and Tom Richford, Harry’s parents, were “enormously excited” when they found out they were going to be parents for the first time. The parents were young and healthy, and did everything they could to ensure Harry was born in the best possible condition. Sarah was assessed as low risk and the plan was for her to deliver Harry on a midwife-led unit.
Sarah was admitted to the midwifery unit at the Queen Elizabeth the Queen Mother Hospital in Margate, Kent, at around 7pm on 31st October 2017. At around 11:20am on 1st November, she was found not to have progressed for some hours and a decision was made to transfer her to the labour ward. The emergency buzzer was pushed just over half an hour later when there were drops in Harry’s heart beat. This led to the transfer to the labour ward and Sarah being placed on a CTG (a continuous monitor of baby’s heart beat) and given a drug called syntocinon to induce contractions.
By 1:30am on 2nd November, the CTG had become pathological (the most concerning category of CTG result). Independent expert evidence accepted at the inquest was that this meant a blood sample should have been taken from the top of Harry’s head (to check for signs of distress in the blood results) or that his birth should be brought forward quickly. The Coroner’s expert concluded that Harry should have been delivered urgently by C-section at 2am, when the CTG became pathological or, at most, within 30 minutes. He was not delivered until 3:32am.
Harry appeared to be lifeless on delivery. There were prolonged attempts to resuscitate him and, when finally ventilated successfully, he was transferred to William Harvey Hospital, Ashford. He sadly died seven days later of hypoxic ischaemic encephalopathy, a type of serious brain damage.
How did the NHS Trust fail Harry Richford and his parents?
From the above brief summary, you can gather why there were concerns over the circumstances Harry’s death. The exact details, however, are shocking.
The Coroner accepted evidence from an independent expert midwife that the interpretation of Sarah’s CTG by the midwives fell far below the standard expected of them. The expert evidence was that Sarah was given too much syntocinon and that there was a failure to notice that it was causing ‘hyperstimulation’ of her uterus. This can lead to extremely serious, or even fatal, outcomes for both mother and baby. Instead of decreasing the syntocinon, it was increased. This made Harry vulnerable at the time of his birth.
In addition, overnight from 1st to 2nd November, Sarah was being cared for by a locum registrar who was only on his third night at the hospital. It was later found that no one at the Trust had taken responsibility for hiring him, checked his CV or assessed his skills. He was left alone on this night to care for patients with no supervision from a consultant, despite no one knowing the extent of his ability or experience.
The registrar attempted to deliver Harry using forceps which, in this particular scenario, was described as completely inappropriate by the Coroner’s expert. During the C-section, which was a very difficult operation, the registrar called a consultant but said he was happy to deliver the baby himself. The Coroner’s expert stated that a consultant should have been present. The registrar did not ask for a consultant’s help and the consultant did not ask him about his experience in performing C-sections, which was minimal.
At the time of Harry’s delivery the situation in theatre was chaotic and terrifying for his parents. The Coroner’s independent expert neonatologist provided evidence that, although Harry’s condition on delivery was poor, he would have lived and likely suffered no irreversible brain injury had he received prompt and effective resuscitation. However, following his delivery, there was a failure to secure his airway; the responsibility was handed from the only trained member of the team to an untrained junior doctor without the necessary skills. This caused a prolonged period without oxygen. This situation persisted until the anaesthetist treating Sarah put her under general anaesthetic to prevent her from witnessing any more of the panic in the room and stepped in to intubate Harry around 28 minutes after he was born. There were around 20 people in the room. No proper contemporaneous notes were kept. A paediatric doctor gave evidence that he could have called his consultant, who was on call and asleep upstairs, and therefore available to attend.
Failings in Harry’s care
The Coroner found seven failures in Harry’s care, including:
- the hyperstimulation with syntocinon;
- that he should by been urgently delivered within 30 minutes of the pathological CTG;
- that the delivery should have been carried out by a consultant, who should have attended earlier;
- that the locum registrar had not been assessed and had been left unsupervised;
- that there was a failure to effectively resuscitate Harry;
- that a paediatric consultant was not called early enough; and,
- that there was a failure to keep a time log of the resuscitation.
The Coroner also made a Prevention of Future Deaths report which made 19 recommendations. The family’s own website states that they understand this to be a record number. The recommendations include: that there should be a review, at national level, of recruitment, assessment and supervision of locum doctors and there that there should be Trust reviews of policies, such as the action taken following a pathological CTG, ways to get consultant help even if they are at home and cannot attend immediately, training procedures for neonatal resuscitation, ensuring knowledge of all relevant guidelines and audits on the quality of record keeping.
In his judgment the Coroner wrote: “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 still grieving, and will no doubt for the rest of their lives.” His family have made a statement following the CQC charges saying they are pleased the landmark decision has been made.
The CQC’s power to prosecute
The CQC’s power to prosecute was created in 2015 as part for a raft of changes brought in in response to the Mid Staffordshire Hospitals patient care disaster from 2005 to 2009. The findings of an inquiry into that scandal found, amongst other systematic failures at several levels, an unacceptable willingness to tolerate poor standards of patient care and a failure to accept and respond to legitimate complaints.
In addition to all the failures in Harry’s care, the Coroner describes a “seemingly incomprehensible decision” on the part of East Kent Hospitals University NHS Foundation Trust, who are responsible for the hospital, to describe his death as “expected”. This meant the Coroner was not informed of the death by the Trust and it was down to the persistence of Harry’s parents and their families to push for an inquest to be ordered.
What can NHS Trusts do to properly manage future cases like this?
Following a tragedy such as this, it is hugely important that the Trust are open and honest not only with the family but in the process of notifying the relevant authorities. The Coroner noted that “Without a full inquest such as this the family would never have had the opportunity to see and hear from those involved in the care of their son, let alone question them in detail… or to give evidence themselves.”
The family have spoken out previously about how they feel the Trust did not learn lessons from Harry’s death, after a report from the Healthcare Safety Investigation Branch found recurrent safety risks in the Trust’s care and that, despite repeatedly raising the concerns, the same themes were recurring within maternity care at the Trust. There will now be an independent review into East Kent maternity services.
A milestone for patient safety
The decision by the CQC to prosecute marks a milestone for patient safety. So much time has passed since the shocking events of Mid Staffs, and the inquiry report of 2013, but we still hear about Trusts displaying recurring problems with care, reinforcing the concern that the standards are not up to scratch and lessons are not being learnt. A 2015 report into the Morecambe Bay maternity scandal found the deaths of 11 babies and one mother were avoidable. This week an inquest into the death of baby Wynter Andrews in Nottingham heard that she died due to systemic errors on a maternity ward considered, months before, to be unsafe.
This prosecution (the first in respect of unsafe care), along with others like the recent, first-ever, prosecution for failing to be open and honest, may represent the firm hand needed to turn the tide in systems that are resistant to improvement.
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