An NHS trust has been fined a record £761,000 following a landmark prosecution by the CQC for the trust’s failure to protect baby Harry Richford and his mum Sarah Richford from avoidable mistakes that led to Harry’s death.
East Kent Hospitals University Foundation Trust was handed the fine today at Folkestone Magistrates Court after pleading guilty in April to failing to provide safe care to mum Sarah Richford and her baby Harry Richford.
It is the first prosecution of its kind by the Care Quality Commission (CQC), where an NHS trust failed to provide safe clinical care to patients.
Harry died as a result of “wholly avoidable” mistakes by staff at the Queen Elizabeth The Queen Mother Hospital in Margate, in November 2017. He was delivered by caesarean section but delays helping him to breathe led to him suffering a severe lack of oxygen and brain damage.
A coroner ruled the mistakes amounted to neglect by the trust which had failed to act on earlier safety warnings that could have helped prevent the tragedy.
The trust is now facing a wider inquiry by Dr Bill Kirkup into almost 200 maternity cases, including the deaths of other mothers and babies and children left with severe brain damage. Police are also considering a criminal investigation into the poor maternity care.
In a statement to the court Harry’s mother Sarah said: “There’s no way I can truly encapsulate the pain upset and anger that I’ve experienced after what happened to Harry at his birth.
“I never imagined that I would feel so helpless, exhausted and distressed lying on an operating table listening to a room full of panicking people who I was relying on to safely deliver Harry.”
She said the poor care she and Harry were subjected to was “inexcusable”.
District judge Justin Barron said it was a “truly powerful, moving account” of what happened.
He said the aim of his sentence was to “bring it home” to the trust that it needed to change adding: “It has to put in place practices and procedures to ensure that what happened to you, doesn’t happen to anybody else.”
There were clear “system failures” he said adding: “I don’t have any difficulty finding that this is a case of high culpability” and “the highest category of harm,” he said.
“It caused the greatest harm imaginable.”
He said it was clear lessons had not been learned from reports by the Royal College of Obstetricians when Harry died and that the family had to campaign to get answers.
Judge Barron said action was now being taken by the trust including recruiting seven consultants and more than a dozen senior midwives.
He set a starting point for his fine at £1.1 million but said: “I have to have regard to the fact that this isn’t a private company this is the NHS providing care across the wider community, that isn’t going to be reimbursed by government. And if the fine I impose is to swinging it will have a direct impact on patient care, and that isn’t my aim as a judge.”
The fine was reduced by a third because of the trust’s early guilty plea resulting in a fine of £733,000 plus costs of £28,000 and a victim surcharge of £170, totally £761,170.
The court heard the trust had failed to carry out proper checks on a locum registrar, Dr Christos Spyroulis, before he was able to work shifts in the maternity unit. He did not go through an induction process and his abilities were not assessed. The court was told Dr Spyroulis was also poorly supervised by more senior doctors.
Philip Cave, director of finance and performance, was asked to read a statement to the court on behalf of the trust and directed by the judge to read it directly to Harry’s parents who were sitting in court.
He said the trust did have insight into the failures that led to Harry’s death adding: “These two 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 of supervision, system failures and failure to improve practice.
“I recognise that parents of loved ones should not have to campaign to achieve change, and it’s testament to their characters against the background and unimaginable loss they have done so. The board is determined to improve the quality of care and advice those who use and depend on its maternity services.”
The wider failings at the trust and in Harry’s treatment were exposed by his family and in particular his grandfather, Derek Richford, who was initially told by the CQC in 2018 that following an “extensive review, we do not believe there has been a breach in regulation”.
In January 2020, The Independent revealed there had been dozens of baby deaths at the trust.
Between 2014 and 2018 there were 68 baby deaths for children aged under 28 days old and of those, 54 died within their first seven days. There were 143 stillbirths with 138 starved of oxygen during their birth.
In a statement Harry’s family said: “Mistakes happen every day, and in a hospital, this will lead to death, we have, over time, come to accept this. 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.”
They added: “Although we are happy that a sanction has been delivered, we 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. This is not a criticism of the CQC or Judge Barron’s decision which is restricted by current guidance.”
Niall Dickson, chair of East Kent Hospitals University Foundation Trust, said after the court hearing: “I want to begin by saying how sorry we are for Harry Richford’s death and to apologise unreservedly to his family for our failure to provide safe care and treatment for Harry and for his mother, Sarah.
“Harry’s parents expected that they would return home with a healthy baby and we failed them. We fully acknowledge the mistakes that we made.”