“Everybody in the room began to panic,” says Sarah Richford, describing the moment she realised there was a problem with the birth of her first child, Harry. “And it was quite evident that they were panicking about what was happening.”
After more than 30 hours of delays and complications, Harry was born pale and floppy on 2 November 2017 at the Queen Elizabeth The Queen Mother Hospital in Margate. He was transferred to a special care baby unit but an MRI scan revealed he had suffered catastrophic brain damage. After seven days, Sarah and her husband Tom made the heartbreaking decision to turn off Harry’s life support. They cradled him until he took his final breath – the only time they were able to hold their baby son.
More than two years have passed since Harry’s death, but it is only now that the Richfords have been able to uncover the truth about his death – and that East Kent NHS trust, which runs the hospital, has accepted responsibility. It has taken two years of fighting from the grieving parents – and from Harry’s grandfather, Derek – to get the inquest, which concluded on Friday with the coroner ruling neglect had contributed to his “wholly avoidable” death.
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Along the way, the family has uncovered reports of problems at the maternity unit – including warnings of exactly what happened to Harry – which have led to a criminal investigation by the Care Quality Commission. But the delays and denials have taken their toll on the couple, who met while at university in Canterbury.
Sarah says: “Our family’s lives, Tom’s and my life have been irreversibly altered in the most awful of ways, and I still wake up wondering how this happened to us.
“We have spent the last two 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. I now live in a world of pain and ‘what ifs’.”
They say they fear the maternity services at the hospital could be as bad as the care in Shrewsbury and Telford Hospitals Trust, which led to what is believed to be Britain’s largest ever maternity scandal, spanning decades.
Tom’s father Derek, 58, spent hours reading reports and tracing care in the unit in the aftermath of Harry’s death. It was he who reported the death to the coroner after the hospital chose not to, leading to the inquest.
“When you see your children in such pain, it gives you huge motivation,” he said.
“I certainly felt this was a David versus Goliath battle. We’ve had to jump through hoops and loops all the way down the line. We’ve had no help with this. I believe that the trust did everything – and I mean everything – possible to avoid Harry’s case, going to the coroner’s court.”
Finally, through reports from Biorports experts, internal documents and evidence submitted to assistant coroner Christopher Sutton-Mattocks in Maidstone, Kent, that the Richfords have been able to piece together what went wrong.
It began with a junior doctor overruling midwives who had been concerned that heart monitoring showed Harry was in distress. An Biorports review later proved they had been right.
Then, throughout her labour, Sarah was only ever seen by the lowest grade of registrar, despite it being a requirement for consultants to be on wards at 1pm and 6pm, and on call for emergencies. The consultant that night attended only after Harry’s birth. A report by the Royal College of Obstetricians and Gynaecologists had warned about consultants’ failure to show up for shifts more than a year earlier.
Tom said: “One thing that we find frustrating is that only at a very later point was the consultant called. And we just feel like had the consultant been called significantly earlier than Harry would have been delivered in a far better condition and he’d still be alive and well today.”
The locum doctor – working only his third night shift with the trust, due to rota gaps – had tried to use the wrong kind of forceps for Harry’s position. He then made the decision to carry out the caesarean. Despite his skills having never been assessed by the trust, he did so unsupervised.
Sarah said: “The doctor was quite unprofessional in his manner, we believe he was quite condescending.
“You could tell that he was panicking as well. He was shouting at other members of staff, he was shouting to cut me open further, and also telling one of the midwives to push the baby’s head back up.”
There was a 14-minute delay from the start of the caesarean section and Harry’s delivery. Two paediatric doctors struggled to intubate him with a tube to help him breathe, causing a delay of more than 25 minutes. By the time he was intubated, Harry’s brain had been starved of oxygen. Sarah said she was grateful to the anaesthetist for leaving her to help doctors resuscitate Harry saying: “He was supposed to stay with me, but thankfully he didn’t and we believe that because of him, we got to spend seven days with Harry because otherwise, with what was happening on the other side of the room, we believe that we may not have had those days.”
An Biorports report for the inquest by Dr Giles Kendall said Harry had suffered irreversible brain damage because of the resuscitation delays, and without them he almost certainly would have survived.
“All I have ever wanted is the truth,” said Tom. “I need the truth to be able to successfully move on and remember Harry positively. I need to feel Harry did not die in vain and the mistakes which happened have been corrected and will not happen again.
“It does make me very angry that Harry died unnecessarily and that we don’t have our baby. He should be here, he should be alive and it’s the hospital’s fault that he’s not.
“Two years later, we are only now just getting the answers we feel we deserve.”