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In the first ever criminal prosecution of its kind, East Kent NHS Trust has pleaded guilty to causing the death of a seven-day old little boy, Harry Richford, by unsafe clinical care. The successful prosecution follows the findings at the 2020 inquest which concluded that Harry’s death was wholly unavoidable and contributed to by neglect.

Following the inquest, the “Independent Investigation into East Kent Maternity Services” (“Kirkup”) review was set up which will look into the way maternity and neonatal services were delivered at this Trust since 2009. You can read more about the review here: https://iiekms.org.uk/about-the-investigation/.

Families affected have been encouraged to make contact. It is hoped that the report will be published in Autumn 2022.

This review follows earlier similar investigations following evidence of poor maternity care at Morecambe Bay and Shrewsbury and Telford hospitals (“the Ockenden Report”)

Harry’s Story

Harry was born on his due date on 2 November 2017 at the Queen Elizabeth the Queen Mother Hospital in Margate. His mother’s pregnancy was regarded as “low risk” yet what followed, when she attended hospital, was a never-ending sequence of catastrophic errors.

When Harry’s mother’s labour failed to progress, she was transferred from the hospital’s midwifery led unit to the obstetric unit, where she was given syntocinon to help progress her labour. After 25 hours in labour, her care was taken over by a locum Registrar who was only on his 3rd ever hospital shift. It was later found that he had been recruited to the post by an agency and the Trust hadn’t even seen his CV.

Harry was eventually delivered in a very poor condition. Harry was then passed to a junior registrar who was unable to successfully intubate or resuscitate him. An MRI scan revealed that Harry had sustained severe brain damage and his life support was removed. Harry passed away on 9 November 2017, aged just seven days’ old.

The inquest found that that there were a number of gross failings made on behalf of the Trust in relation to the care of Harry and his mother. These included:

  • The inappropriate management of syntocinon leading to the hyperstimulation of the uterus which in turn may have contributed to an hypoxic ischaemic insult;
  • The delay in the delivery of Harry once the CTG recorded the fetal heart rate to be “pathological”;
  • The treating Registrar being inexperienced and unsupervised as well as a delay involving a consultant in the management of mum and baby’s care;
  • The mismanagement of the resuscitation period prolonging the period of hypoxia.

Following a long battle by Harry’s parents to investigate the circumstances surrounding their son’s death, the care regulator, the Care Quality Commission (CQC) prosecuted East Kent NHS Trust. The Trust was charged with exposing Harry and his mother to significant risk or avoidable harm and providing unsafe clinical care as a result.

The family were particularly distraught that many of the findings from the Royal College of Obstetricians & Gynaecologists (RCOG’s) own review into the running of the same obstetric unit in 2015 remained issues 2 years later. This review was arranged following concerns about inconsistent compliance with national standards amongst obstetricians, poor governance in relation to serious incidents, staffing, education and supervision as well as consultant accessibility and responsiveness.

The Healthcare Safety Investigation Branch (HSIB) also investigated and identified 18 findings where practices and policies were not followed in caring for Harry and his mother.

What to do if your family has been through a similar experience

At CL Medilaw, we specialise in investigating clinical negligence claims where mothers and their babies have been injured when appropriate steps have not been taken during pregnancy, labour and following birth, causing severe brain injuries or death. Our team have helped many children and their families to investigate whether steps could have been taken to deliver their children sooner or resuscitate quicker, thus avoiding their injuries.

Our focus at CL Medilaw is to investigate every aspect of obstetric and neonatal care and to challenge the evidence to ensure that every relevant question has been asked. Regrettably, many of our clients will recognise similarities in the care they received to that which Harry’s family experienced, but also the challenges faced to establish why and what has gone wrong.

Contact our team of clinical negligence and birth injury solicitors for free, initial advice and guidance either by calling on 0345 2410 154, or email us via [email protected]

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