Sunday, June 20, 2021

Beleaguered East Kent Hospital. UK: Major Development: The hospital has been fined a whopping 733,000 pounds sterling ($1, 021,654. U.S) over serious failures that led to the death of a one-week old baby, the Guardian (Health Policy Editor Denis Campbell) reports..."A hospital trust has been fined £733,000 over serious failures that led to the death of a week-old baby, in a groundbreaking prosecution brought by the NHS care regulator. East Kent hospitals university NHS (National Health Service) foundation trust was handed the fine at Folkestone magistrates court on Friday over lapses in how its maternity staff treated Harry Richford and his mother, Sarah. The trust pleaded guilty in April to a charge of failing to provide safe care to Harry and his mother after she went into labour and around the time of the birth in November 2017 at the Queen Elizabeth the Queen Mother hospital in Margate, which resulted in them both suffering avoidable harm. “Due to the trust not managing this risk of avoidable harm, following his birth on 2 November 2017 Harry was found to be unwell and placed into incubated care on a ventilator. However, on 9 November, seven days after his birth, Harry died,” the Care Quality Commission (CQC) said.


BACKGROUND:  On May 21st, 2021, I ran my first post on the East Kent hospital system in the UK which had suffered an extraordinary number of baby deaths. The headnote to the post ran as follows: "East Kent Hospital: UK: An estimated 200 baby deaths in recent history in one British hospital - yet you hardly read a word about it outside the UK - even though it is under high level criminal investigation and reportedly considering manslaughter charges..."Detectives are examining a series of baby deaths at a troubled NHS (National Health Service) trust as the number of cases being investigated by an independent inquiry nears 200 – making it one of the worst maternity scandals in NHS history," The Independent (Health Correspondent Shaun Lintern) reports..."The original independent inquiry into East Kent was set up last year after The Independent revealed scores of babies had died at the trust between 2014 and 2018, while more than 100 others suffered brain damage during birth." I expressed my sadness and outrage in the following 'Publisher's Note,' as follows:  "An estimated 200 baby deaths in the East Kent hospital over a period of just four years. That is utterly numbing.  When four babies were reported to have died in the cardiac ward of the Hospital for Sick Children in Toronto -  between July 1980 and March 1981 - the city went into a state of shock, which reverberated throughout the entire country. The thought of 4 dead babies - and the blow to their respective families - is devastating. 200 dead babies is unthinkable. I will be following developments closely. So much more to make one weep. I hope the story will be picked up by others far beyond Britain's borders. As the Independent reports, the UK has experienced a crisis in its maternity wards for years before East Kent - and not much has changed. Perhaps international attention will lead to lasting reform (this time)  and help save baby's lives.  Harold Levy: Publisher: The Charles Smith Blog.https; The entire post can be read at: 

https://smithforensic.blogspot.com/search?q=%22east+kent%22


---------------------------------------------------------------------


This new post (June 20, 2021) is devoted to the massive 733,000 pound fine (1,021,654 US)  levied against the hospital trust over the  serious failures that led to the death of  Harry Richford, a week-old baby - just one prong of the multiple investigations of the hospital that currently under way.


---------------------------------------------------------------------


PASSAGE OF THE DAY: "At an inquest last year, the coroner Christopher Sutton-Maddocks found that Harry’s death was “contributed to by neglect”. He identified a series of blunders that led to the boy being born looking pale, not crying and in a poor state, and later dying. Staff failed to ensure that Harry was born within 30 minutes of a cardiotachography scan showing that his heart rate was worryingly high at 2am on 2 November 2017, he said. Instead it took 92 minutes to deliver him. At 2.05am an inexperienced locum registrar obstetrician, Dr Christos Spyroulis, tried to deliver Harry using forceps but failed. Harry was eventually born by emergency caesarean section at 3.32am but was “to all intents and purposes lifeless”.

 An obstetrics expert said that if Harry had been born at 2am he would have been in a good condition and lived. The coroner said the delivery was complicated and should have been done by a consultant, whom he criticised for arriving late.

The trust is the subject of a government-ordered review of its maternity care led by Dr Bill Kirkup after it emerged that other babies died after receiving what their families said was poor care."


-------------------------------------------------------------

STORY: "Kent Hospital Trust find 733,000 pounds over failure that lead to babies death," by Health Policy Editor Denis Campbell. published by The Guardian on June 18, 2021.

SUB-HEADING: "Case of baby Harry Richford was first prosecution of its kind brought by NHS (National Health Service) regulator."

PHOTO CAPTION: "The East Kent trust is the subject of a review of its maternity care after it emerged that other babies died after receiving what their families said was poor care.


GIST: "A hospital trust has been fined £733,000 over serious failures that led to the death of a week-old baby, in a groundbreaking prosecution brought by the NHS care regulator.

East Kent hospitals university NHS foundation trust was handed the fine at Folkestone magistrates court on Friday over lapses in how its maternity staff treated Harry Richford and his mother, Sarah.


The trust pleaded guilty in April to a charge of failing to provide safe care to Harry and his mother after she went into labour and around the time of the birth in November 2017 at the Queen Elizabeth the Queen Mother hospital in Margate, which resulted in them both suffering avoidable harm.


“Due to the trust not managing this risk of avoidable harm, following his birth on 2 November 2017 Harry was found to be unwell and placed into incubated care on a ventilator. However, on 9 November, seven days after his birth, Harry died,” the Care Quality Commission (CQC) said.


The trust was fined £733,000 for breaching regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and ordered to pay a £170 victim surcharge and £28,000 of the CQC’s costs in bringing the case, meaning it has to pay a total of £761,170.


The sentencing brings to an end the first prosecution of a trust by the CQC for providing criminally inadequate standards of clinical care.


Nigel Acheson, the CQC’s deputy chief inspector of hospitals, said after the hearing: “No family should ever have to endure the pain and suffering that the Richford family have experienced. The trust’s acceptance of responsibility for the errors in Harry and Sarah’s care is welcome, but the fact remains that the series of events which led up to Harry’s death could and should have been avoided.”


While most births occurred safely, he said, “the death or injury of even one new baby or mother is one too many and something that everyone working in the health and care system must do all they can to prevent”.


At an inquest last year, the coroner Christopher Sutton-Maddocks found that Harry’s death was “contributed to by neglect”. He identified a series of blunders that led to the boy being born looking pale, not crying and in a poor state, and later dying.


Staff failed to ensure that Harry was born within 30 minutes of a cardiotachography scan showing that his heart rate was worryingly high at 2am on 2 November 2017, he said. Instead it took 92 minutes to deliver him.


At 2.05am an inexperienced locum registrar obstetrician, Dr Christos Spyroulis, tried to deliver Harry using forceps but failed. Harry was eventually born by emergency caesarean section at 3.32am but was “to all intents and purposes lifeless”.


An obstetrics expert said that if Harry had been born at 2am he would have been in a good condition and lived. The coroner said the delivery was complicated and should have been done by a consultant, whom he criticised for arriving late.


The trust is the subject of a government-ordered review of its maternity care led by Dr Bill Kirkup after it emerged that other babies died after receiving what their families said was poor care.


The trust’s boss apologised to the family. “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,” said Niall Dickson, the chair of the trust’s board.


He outlined improvements made to its maternity services since Harry’s death, including hiring more consultants and extending the hours a consultant is on duty at the hospital in Margate and at the trust’s William Harvey hospital in Ashford."


The entire story can be read at:

PUBLISHER'S NOTE: I am monitoring this case/issue. Keep your eye on the Charles Smith Blog for reports on developments. The Toronto Star, my previous employer for more than twenty incredible years, has put considerable effort into exposing the harm caused by Dr. Charles Smith and his protectors - and into pushing for reform of Ontario's forensic pediatric pathology system. The Star has a "topic"  section which focuses on recent stories related to Dr. Charles Smith. It can be found at: http://www.thestar.com/topic/charlessmith. Information on "The Charles Smith Blog Award"- and its nomination process - can be found at: http://smithforensic.blogspot.com/2011/05/charles-smith-blog-award-nominations.html Please send any comments or information on other cases and issues of interest to the readers of this blog to: hlevy15@gmail.com.  Harold Levy: Publisher: The Charles Smith Blog;
-----------------------------------------------------------------
FINAL WORD:  (Applicable to all of our wrongful conviction cases):  "Whenever there is a wrongful conviction, it exposes errors in our criminal legal system, and we hope that this case — and lessons from it — can prevent future injustices."
Lawyer Radha Natarajan:
Executive Director: New England Innocence Project;
—————————————————————————————————
FINAL, FINAL WORD: "Since its inception, the Innocence Project has pushed the criminal legal system to confront and correct the laws and policies that cause and contribute to wrongful convictions.   They never shied away from the hard cases — the ones involving eyewitness identifications, confessions, and bite marks. Instead, in the course of presenting scientific evidence of innocence, they’ve exposed the unreliability of evidence that was, for centuries, deemed untouchable." So true!
Christina Swarns: Executive Director: The Innocence Project;