East Kent NHS Maternity Claims

The case of baby Harry Richford, who died in 2017, was instrumental in deeper investigations being made into the standard of East Kent maternity care.

Harry was born in a hospital in Margate in an emergency delivery. He was transferred to the intensive neonatal unit at William Harvey Hospital in Ashford, but later died.

The Trust insisted a coroner did not need to be informed of his death and that an inquest was not required.

However, Harry’s family contested this, and secured an inquest having contacted the coroner directly themselves.

During the inquest, more than a dozen areas of concern were highlighted over the care of Harry and his mother, including failings in the way an ‘inexperienced’ doctor carried out the delivery, followed by delays in resuscitation.

The coroner found Harry’s death was contributed to by neglect. He had died seven days after his delivery from a condition caused by a lack of oxygen.

An independent report said he might have survived had there not been a delay in resuscitation at his birth that caused irreversible brain damage. The case prompted the review which has now taken place, commissioned by NHS England and NHS Improvement. In June 2021 the Trust was fined £733,000 for failures following a Care Quality Commission (CQC) prosecution.

The Independent Investigation has examined maternity and neonatal services since 2009 (when the Trust came into being) by looking in particular at the following four areas:

• What happened at the time, in individual cases, independently assessed by the investigation?
• When things went wrong in individual cases, did the Trust respond and seek to learn lessons?
• How did the Trust respond to signals that there were problems with maternity services more generally, including in external reports?
• How did the Trust engage with the bodies involved and seek to apply the relevant messages? And what were the actions and responses of the regulators and commissioners?

The investigation started on 23 April 2020 and several families came forward at that stage. On the 1st October 2020, as Chair of the Independent Panel, Dr Kirkup issued an invitation for more families to come forward, resulting in many more doing so.

The investigation considered:

• The experiences of families and the impact on them.
• The medical records of patients.
• Corporate records showing how the Trust discharged its responsibilities for maternity services.
• How the Trust communicated and engaged with patients, their families and representatives and with regulators and others over concerns with maternity services.
• Interviews with those whose work involved maternity services.
• Interviews with regulators, NHS England and Improvement, HSIB and others.

The report found that, from 202 cases reviewed, up to 45 babies may have survived had they received better treatment at the William Harvey Hospital in Ashford and the Queen Elizabeth the Queen Mother Hospital in Margate. A further 12 babies may not have suffered brain damage and 23 mothers may not have died or been injured. Failings were also found in the care of a further 54 patients.

The report is to be published and presented to Parliament with the aim of agreeing with NHS England and NHS Improvement steps which can be taken to help ensure that the lessons identified are understood and acted upon.