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East Kent Hospitals fined £733k after admitting providing unsafe care and treatment of baby Harry Richford resulting in his death

East Kent Hospitals has been fined £733,000 for the unsafe care and treatment of a baby which resulted in his tragic death.

The trust was sentenced today at Folkestone Magistrates Court in the case of Harry Richford, who died following a catalogue of failures during his birth at the QEQM Hospital in Margate in November 2017.

Harry Richford was born at QEQM Hospital
Harry Richford was born at QEQM Hospital

In April, after a criminal case was brought by the Care Quality Commission - the first of its kind - East Kent Hospitals pleaded guilty to the charge that it caused Harry and his mother Sarah Richford, from Birchington, harm by failing to provide safe care and treatment.

During today's proceedings, the list of failures by the trust were outlined, focusing on the shocking events of the labour.

The hearing also heard about the insufficient checks carried out on the inexperienced locum who was in charge during the birth of Harry, whose death has led to other maternity cases being examined and a national investigation into services in east Kent.

Parts of emotional statements from Sarah and Tom Richford were read by Judge Justin Barron, in which the heartbroken parents admitted they have "cried themselves to sleep on countless occasions".

Mrs Richford, who has suffered 'psychological injury' from the trauma, said: "I placed my complete trust into all the health professionals and specialists we encountered, however, some of the care Harry and I were subjected to was dire and inexcusable.

"We have spent the last three years trying to carry on with life and all I feel is devastating sadness and anger at the NHS for not treating us with the respect we deserved after such awful mistakes were made."

Before passing sentence, Judge Barron said he had no reason to doubt the commitment the trust is now making to make changes and improvements.

He also explained the difficulties with sentencing in such a case and deciding on a suitable fine as punishment.

"It's not about quantifying a baby's life, you can't do that - if I fined £50 million it wouldn't make any difference to the suffering and trauma that the family has been through," he said.

"It wouldn't be a way of quantifying Harry's value. It's not quantifiable.

"The fine isn't about putting a value on life, it's about punishing the trust, but there is the added complication in that if I went completely mad and fine tens of millions of pounds, that is going to impact patient care. So this is the balance I need to make."

Judge Barron ordered a fine of £733,000, which had been reduced from an initial 'starting point' of £1.1 million due to the fact there was a guilty plea made.

The trust must also pay £28,000 in costs.

Harry Richford
Harry Richford

He said: "If this was a private company I was dealing with in relation to the death of a baby, then this fine would be too low.

"But I have to have regard to the fact this is the NHS providing care across the wider community, and that isn't going to be reimbursed by government.

"If I was to be swingeing it would have a direct impact on patient care. That's not my aim as a judge or Mr and Mrs Richford's aim as parents.

"It's their aim to ensure the trust recognises its failings and improves for the future and to ensure that no one else goes through what they've gone through."

Commenting after the proceedings, the Richford family said the failure of East Kent Hospitals to learn from its errors over many years led to the significant failings witnessed in Harry's death.

"Mistakes happen every day, and in a hospital, this will lead to death. We have, over time, come to accept this," they said.

"Learning from these errors is vital and what makes hospitals a better and safer place for all.

"Sadly, both individual and systemic errors were pushed aside for many years with no learning taking place.

"This failure to learn has led to the significant failings witnessed in Harry’s death and no doubt countless others which are now being investigated by Dr Bill Kirkup and his team in the East Kent Maternity Inquiry.

"Had these failings been addressed promptly and effectively we would not be here today. We are not here because of the failings from one evening."

Sarah and Tom Richford speaking after the inquest
Sarah and Tom Richford speaking after the inquest

The family say while they are pleased East Kent Hospitals pleaded guilty and a sanction has been delivered, they are unsure if the system currently in place is suitable for public-funded organisations such as NHS trusts.

"Taking money away from a financially-challenged resource does seem counterintuitive and we would encourage policy makers to consider any alternative options," they said.

"This is not a criticism of the CQC or Judge Barron’s decision which is restricted by current guidance."

They added: "Having our lives thrown into the public eye is not what anybody wants to do but sadly this was needed to shine a light on the failings which led to Harry’s death in 2017.

"We would now ask to be given the privacy to take today’s news on board and will privately support any future investigations to ensure long-lasting change at local and national levels is a legacy Harry’s life fulfilled and to help less families have to suffer unnecessary birth injury or bereavement."

Last year, a coroner ruled that Harry was failed by the hospital following a three-week inquest which found the tot's death was "wholly avoidable".

The inquest heard evidence detailing a series of worrying incidents in the lead-up to his birth and distressing details of the panic-stricken medical team who delivered him.

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.

QEQM Hospital in Margate. Picture: Google Street View
QEQM Hospital in Margate. Picture: Google Street View

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 exhausted mother was rushed into theatre, where medics attempted to deliver Harry with forceps before an emergency caesarean was performed by an inexperienced locum.

When he was born "silent and floppy" an anaesthetist dealing with Sarah had to step in after 28 minutes after a locum registrar failed to get him to breathe.

Had Harry been successfully resuscitated within 10 to 15 minutes of being delivered he would have survived and not suffered irreversible brain damage.

Once intubated, he had to be transferred to the neonatal intensive care unit at the William Harvey Hospital in Ashford.

He was so unwell his parents were not able to hold him until the morning of the day he died from hypoxia, on November 9, 2017, aged just a week old.

The CQC started a formal criminal investigation in October 2019 and the trust was charged with exposing Harry and his mother to significant risk of avoidable harm.

It was brought under Regulation 12 of the Health and Social Care Act, and is the first prosecution of its kind to relate directly to clinical care.

During today's proceedings, the CQC prosecution outlined failings of East Kent Hospitals, including the failure to check the experience and limitations of the locum who delivered Harry and lack of competancy assessments.

Philip Cave, director of finance and performance at the trust, read a statement expressing regret from East Kent Hospitals, which serves a patient population of 700,000.

'Harry’s parents expected that they would return home with a healthy baby and we failed them' - Niall Dickson, EKH chair

"These patient safety events were caused by a number of factors including failures to ensure baby Harry's and Mrs Richford's safety, poor clinical leadership, poor governance, human error, clinical and healthcare errors, failures with supervision, system failures and failures to improve practice," he said.

Mr Cave said the trust has made improvements and taken on 200 more full time employees, including more consultants and midwifery staff.

In a statement after the hearing, Niall Dickson CBE, chair of East Kent Hospitals, says the trust "apologises unreservedly" to the Richford family.

"Harry’s parents expected that they would return home with a healthy baby and we failed them," he said.

"We fully acknowledge the mistakes that we made.

"I share the commitment of our midwives and doctors who work to provide high quality maternity care to the thousands of women who give birth at our hospitals each year.

"I know that today we have more senior doctors, more stringent checks on those we employ, strengthened training for our maternity staff and better monitoring of babies during labour. There is always more to do and we will continue to build on the steps that have been taken to improve the service we offer.

"A critical part of that must be making sure we listen to women and their families.

"Our maternity service is being independently reviewed by Dr Bill Kirkup and his team. We welcome that and are determined to learn any lessons that emerge from that investigation.

"Learning and efforts to improve should never stop and we will continue to work tirelessly to provide a high-quality maternity service, which continually strives for improvement and is safe, effective, and centred on the women and children under our care."

During the hearing, the CQC highlighted a 2016 report by the Royal College of Obstetricians and Gynaecologists which found significant problems across the QEQM and the William Harvey.

Issues highlighted were consultants not carrying out ward rounds, attending out-of-hours calls when requested or completing mandatory training, but the CQC says improvements did not happen.

Harry's death has led to numerous other cases of maternity incidents emerging.

Last year, the hospital trust's board admitted the number of potentially avoidable baby deaths could be as many as 15 in seven years.

The trust is currently the focus of an independent inquiry by Dr Bill Kirkup, who led the probe into the Morecambe Bay baby death scandal.

It is looking into the standard of care provided by the maternity and neonatal service at EKH since 2009, the year it became a foundation trust.

Families who believe they received poor clinical care from the trust have been encouraged to come forward and the number is believed to be at almost 200.

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