The death of a baby just seven days after his birth at the QEQM hospital in Margate was "wholly avoidable", an inquest has found.
A coroner has ruled today that tiny Harry Richford was "failed by the hospital" as he delivered a narrative verdict following a three-week inquest into his death.
The Richfords speaking to KMTV after the inquest
Harry was born at the QEQM on November 2, 2017, after a long labour and chaotic delivery by emergency caesarean, performed by "panicked" medics.
When he was eventually delivered he was so unwell he had to be transferred to the neonatal intensive care unit at the William Harvey Hospital in Ashford.
After just seven days, Harry died of hypoxia, a condition caused by lack of oxygen, leaving his parents Tom and Sarah, from Birchington, heartbroken.
Highlighting a series of failures as he reached his conclusion, Christopher Sutton-Mattocks said: "I do find that some failures in Harry's case to be the result of neglect.
"Harry's death was wholly avoidable.
"His parents were failed by the hospital and Harry was failed."
The inquest found:
1) Harry was hyperstimulated by excessive use of the drug Syntocinon, used to progress labour for over 10 hours.
2) Once the CTG reading had been 'pathological' Harry should have been delivered within 30 minutes at 2am. Instead he was delivered at 3.32am - 92 minutes later.
3) Delivery was difficult and should have been done by a consultant, who should have arrived earlier.
4) An inexperienced locum who had not been assessed should not have been allowed to deliver Harry unsupervised.
5) Failure to secure an airway during resuscitation leading to a prolonged period of postnatal hypoxia.
6) Failure to request consultant support early during resuscitation.
7) Failed time-keeping during resuscitation, meaning loss of control.
8) His death was contributed to by neglect.
Evidence detailing a string of worrying incidents in the lead-up to his birth and distressing details of the panic-stricken medical team who delivered him have been exposed at the three-week inquest.
It was heard how little Harry's heart rate dropped frequently throughout the long labour and there was a disagreement between staff over whether to administer the drug Syntocinon to progress labour.
Questions were also raised over whether Mrs Richford was suffering from the dangerous condition uterine hyperstimulation, which can impact the baby's heart rate.
The hearing was told how the mum-to-be, who was deemed low-risk throughout her pregnancy, was rushed into theatre where medics attempted to deliver Harry with forceps before performing an emergency caesarean.
Dr Christos Spyruolis, who delivered Harry, was a locum who had not been assessed by the trust and was on only his third shift at the hospital.
He was also too inexperienced to carry out the delivery unsupervised.
"Harry's death was wholly avoidable. His parents were failed by the hospital and Harry was failed"
Had Harry been successfully resuscitated within 10 to 15 minutes of being delivered he would have survived and not had irreversible brain damage.
Dr Dhir Gurung, the anaesthetist dealing with Sarah Richford, stepped in to help after 28 minutes and intubated Harry.
Had it not been for him, said Mr Sutton Mattocks, the Richfords would not have had those precious seven days with their child.
Mrs Richford admitted medical staff sounded out of control and she heard Dr Spyruolis, who delivered Harry, shouting to a midwife to 'push his head back up'.
When her son was born "silent and floppy" Dr Gurung had to step in to help resuscitate him after a locum registrar failed to get him to breathe.
He was so unwell his parents were not able to hold him until the morning of the day he died.
During the inquest, it emerged that despite the catalogue of failures which led to Harry's death, the hospital trust refused to call the coroner numerous times, filled out the statutory death notification form to say his death was expected and completed an MBRRACE-UK form, which investigates maternal deaths, incorrectly to say there were no delivery complications.
Bosses at East Kent Hospitals, which runs the QEQM, have admitted standards of care "fell short" and apologised to the couple.
In a statement released today Dr Paul Stevens, the medical director for East Kent Hospitals, said: “We are so sorry and apologise wholeheartedly for the devastating loss of baby Harry.
"We fully accept that Harry’s care fell below the standard that we want to offer every mother giving birth in our hospitals.
“Mr and Mrs Richford’s expectation in November 2017 was that they would welcome a healthy baby into their family and we are deeply sorry that we failed in our role to help them do that.
“We recognise the mistakes in both Harry’s delivery and subsequent resuscitation and acknowledge that there are things that we could and should have done differently.
"With great sadness we accept that we failed Harry and his family, and apologise unreservedly.
“We are also truly sorry that Harry’s family was not given the support and answers they needed.
"We deeply regret the extra pain that our delays have caused them.
“We cannot imagine the pain the Richford family has endured. The lessons we can learn from their continued commitment to understanding the circumstances of Harry’s death will help families in the future.
“We fully accept the Coroner’s findings and recommendations.
"We are determined to learn when things go wrong and have already made significant changes to our service following Harry’s death.
"Our midwives, doctors and every member of our staff constantly strive to give good care and seek to improve every day.
"The lessons we can learn from their continued commitment to understanding the circumstances of Harry’s death will help families in the future"
“We are working closely with national maternity experts to make sure we are doing everything we can to make rapid and sustainable improvements.
"We are committed to learning the lessons from Harry’s death.”
Mr and Mrs Richford, who are both teachers, are now calling on the Secretary of State for health Matt Hancock for an independent investigation or inquiry into maternity services.
Mr Richford said: "Sarah had a textbook pregnancy and Harry was born on his due date with no abnormalities, but due to failures of both the delivery and resuscitation of Harry he died seven days later.
"Since then the trust has tried to avoid outside scrutiny and failed to learn from this and previous similar cases.
"They refused to call the coroner numerous times, they filled out the statutory death notification form to say that Harry's death was expected and completed the MBRRACE-UK form incorrectly to say that there were no delivery complications.
"This system is specifically designed to aid national learning of infant deaths.
"Accidents happen every day but failing to learn from them appears to have become part of the culture of this NHS trust."
Mr Richford says the trust knew of the risks to pregnant women and babies in its care and failed to learn from previous, serious incidents dating back to 2014 and did not act on findings in an audit report by the Royal College of Obstetricians and Gynaecologists in 2015.
"Had they learned from all of those other cases we wouldn't be stood here today and Harry would still be alive," he said.
"I'm not yet convinced they have the resources or systems in place to prevent more deaths.
"I hope Harry's case can be a turning point to ensure this doesn't happen to anyone else going forwards."
Mr Richford says the emotional impact has been significant.
"Words can't do it justice," he added.
"We've suffered a lot over the past couple of years and we hope today is the start of a new beginning for us."
The couple's North Thanet MP, Sir Roger Gale, said: "First, I would like to commend the courage and quiet dignity with which my young constituents, Tom and Sarah Richford, have conducted themselves since the death of their infant son, Harry, and throughout the process since.
"I have been engaged in this sad case since the family approached me following their loss and it is immediately apparent that their only concern has been to seek to ensure that no other young family has to suffer as they have done.
"To lose a child is terrible. To know that that loss could and should have been prevented adds immeasurably to the pain.
"There have been many failings, both medical and administrative, in this case.
"The coroner has determined that Harry's death was avoidable and I believe that in the early stages the hospital authorities were obstructive in their efforts to prevent the facts from being established.
"What should have been a straightforward process therefore contributed to the family's ordeal.
"Many changes have already been made as a result of this case and more must follow.
"I have discussed the matter personally with the Secretary of State and Matt Hancock has assured me that there must be full transparency in further inquiries that will have to be undertaken and that every last lesson possible must be learned to prevent any repetition of this kind of tragedy and to restore full confidence in the maternity services within the East Kent Hospitals Trust.
"We owe that to the Richford family, to future mothers using the service and to a dedicated team of staff within maternity at the QEQM who wish to provide the best possible facilities and attention to those, mothers and babies, in their care.
"Harry Richford's death cannot be allowed to have been in vain."
In a separate report by the Royal College of Obstetricians and Gynaecologists, drawn up in 2015 but not handed to the Care Quality Commission by the hospitals trust until last year, investigators share worrying findings concerning the QEQM in Margate and the William Harvey in Ashford - but mainly at the Margate site.
"I would like to commend the courage and quiet dignity with which my young constituents, Tom and Sarah Richford, have conducted themselves since the death of their infant son, Harry, and throughout the process since"
It includes a reluctance by consultants to attend maternity units when requested and inconsistent rounds by them on the labour wards.
Investigators also found maternity units were 'vulnerable' out of hours and that there were poor labour ward facilities at both sites.
Concerns were also raised over consultants failing to attend training for CTG - the process which monitors a baby's heart rate during labour.
In the report, seven cases were detailed where serious incident reviews had been carried out, with two involving the deaths of babies.
Further research by The Independent, found between 2014 and 2018 there were 68 baby deaths at the trust for children aged under 28 days old.
Of those, 54 died within their first seven days.
In total, 138 babies suffered brain damage after being starved of oxygen during birth.
There were 143 stillbirths, which includes some late terminations.
About 7,000 babies are born under the care of East Kent Hospitals each year – just under 4,000 at the William Harvey Hospital, Ashford, and just under 3,000 at QEQM.
A spokesman for the trust said: "We recognise that we have not always provided the right standard of care for every woman and baby in our hospitals and we wholeheartedly apologise to families for whom we could have done things differently.
"We are reviewing our service with some of England’s leading maternity experts to make sure we are doing everything we can to make rapid improvements to maternity care in east Kent."
Any expectant mothers who would like reassurance about their care or women who have been under the care of East Kent Hospitals maternity service in the past and have concerns about their care can call the trust on 01233 651900.