Harry Richford with his parents: his death was avoidable
With a major investigation still continuing in Shropshire, examining hundreds of potential failures of maternity care, yet another hospital Trust is under investigation for chronic failures in maternity care, resulting in loss of life. And as so often seems to be the case, poor quality care and a toxic management culture have been linked with low levels of investment, staff shortages, poor morale, and bullying.
It took a prolonged campaign by the family of baby Harry Richford, who died at Queen Elizabeth the Queen Mother Hospital in Margate back in 2017, to even secure a proper inquest.
And it’s the findings of that 3-week inquest that his death was “wholly avoidable” that has finally forced ministers to call an independent inquiry into the chronic failure of health care and management at the East Kent Hospitals Trust’s maternity department.
According to the BBC, 26 maternity cases at the Trust going back to 2011 are already being investigated by the Healthcare Safety Investigation Branch, amid fears of at least seven preventable baby deaths since 2016.
The new inquiry is to be headed by Dr Bill Kirkup, who chaired the 2015 inquiry into maternity service failures at Morecambe Bay, and who was one of the witnesses criticising the East Kent Trust at the inquest. Key lessons of that inquiry have plainly not been learned in East Kent.
Chief Executive Susan Acott, who had consistently tried to minimise the scale of the problem, despite a coroner’s ruling last month that Harry Richford’s death resulted from neglect in the maternity unit of East Kent Hospitals NHS Trust, was accused of being “in denial” by Harry’s grandfather Derek Richford.
He had had to battle for six months even to get the Trust to report Harry’s death to the Coroner, and told BBC Radio 4’s Today Programme that a so-called “root cause analysis” report by the Trust, signed off by the Medical Director, had concluded there was no need for the Coroner to be called in.
In the event the coroner identified SEVEN serious failings by the Trust. Expert reports commissioned by the Coroner on midwifery, obstetrics and paediatrics all found multiple failures, pointing the finger not just at the professional staff but also at the system of care and the Trust’s senior management, who have refused to resign, despite being urged to do so at the Board meeting by public governor Alex Lister.
Worse still there repeated early warnings of problems had been ignored, including a damning report by the Royal College of Obstetricians and Gynaecologists back in 2015, which revealed that senior medical staff frequently failed to turn up for evening and weekend shifts at the Margate Hospital, and junior staff had seen little point in reporting this or other safety concerns because management had done nothing in response to previous reports.
Junior staff were fearful of harassment and intimidation, and noted that even where safety errors were reported no action was taken by the trust.
Nor have the Care Quality Commission come well out of this: in 2016 and 2018 their inspections rated the Trust “requires improvement” on four of the five standard criteria, but there has apparently been no further follow up and the CQC seems not to have seen or received the RCOG report until January last year.
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