A hospital has pleaded guilty to the unsafe treatment of a baby who died after a traumatic birth involving a catalogue of errors in an historic case.
In an unprecedented case that saw an NHS trust prosecuted over poor care for the first time, East Kent Hospitals Trust today admitted it caused Harry Richford and his mother Sarah harm by failing to give safe care and treatment.
Little Harry died after a traumatic birth at the Queen Elizabeth The Queen Mother Hospital in Margate, Kent, in November 2017.
The young boy was delivered "silent and floppy" after a string of mishaps during his birth, with his parents only able to hold him on the morning of the day he died.
At Folkestone Magistrates Court today the trust pleaded guilty to two counts of failing to provide care and treatment in a safe way resulting in harm or loss.
The trust was accused of failing "to provide safe care and treatment exposing a service user...to a significant risk of avoidable harm".
The family said it welcomes the guilty pleas as it will avoid the awful details of his birth having to be replayed in public once more.
In a statement they said: "This is the first case of a criminal prosecution of an NHS trust for poor clinical care by the Care Quality Commission and demonstrates the severity of issues that were discovered.
"Although this case is about Sarah and Harry, it also led to numerous contacts from other families who found themselves in a similar position at the Trust.
"We have encouraged such families to come forward to the Kirkup Inquiry and now believe that the number of families is approaching 200."
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.
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, the inquest heard.
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, leaving his parents Tom and Sarah, from Birchington, devastated.
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.
Harry's death 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 Healthcare Safety Investigations Branch (HSIB) is currently examining three individual maternity cases.
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 and also worked on the investigation into the Hillsborough football disaster.
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.
Following Harry’s inquest in January of 2020, an expert team was put into the trust to deal with the issues raised by the coroner, the CQC and HSIB.
The Richford family said: "Since that time, neonatal deaths have dropped by 55 per cent and still births by 20 per cent compared to the seven-year average.
"This proves that with the right level of focus, leadership and attention, baby’s lives can be saved.
"Harry’s life and our sacrifice has made a significant difference here in East Kent and it must be maintained."
Speaking after the hearing, East Kent Hospitals chief executive, Susan Acott, said: "We are deeply sorry that we failed Harry, Sarah and the Richford family and apologise unreservedly for our failures in their care.
"We are determined to learn when things go wrong. Our midwives, our doctors and every member of our staff constantly strive to give good care every day.
"We have already made significant changes following Harry’s death and we will continue to do everything we can to learn from this tragedy.
"We are working closely with national maternity experts to make sure we are doing everything we can to make rapid and sustainable improvements.
"We have welcomed the independent investigation into maternity services in east Kent and we are doing everything in our power to assist and support the investigation."
The charges levelled at the trust stated it "failed to discharge a duty imposed on it...where care and treatment was not provided in a safe way" for patients - in this case for both Harry and his mother.