Harry Richford was born at the Queen Elizabeth the Queen Mother Hospital (QEQM), Margate, Kent on 2/11/17. He died on 9/11/17 at the William Harvey Hospital, Ashford to where he had been transferred. The cause of death was 1a Hypoxic Ischaemic Brain Encephalopathy. There was a narrative conclusion setting out some seven failures in the care of Harry Richford together with a conclusion that his death was contributed to by neglect.
Coroner's concerns and recommendations
- X was recruited as a locum registrar by the Hospital Trust without there appearing to have been any assessment of his skills and abilities or any supervision of him at the hospital. This was not an emergency appointment after, for example, a doctor calling in sick at the last minute. X gave evidence that the recruitment, assessment and supervision of locums is a national problem and that there is a need for a review on a national level. This raises concerns that there may be a risk to other lives both at this trust and at other trusts in the future.
- NHS England and the Royal College of Obstetricians and Gynaecologists consider a review at a national level into the recruitment, assessment and supervision of locum on obstetric and gynaecology wards together with the publication, if appropriate, of new guidelines. Particular emphasis should be 9 considered upon delineating the permitted scope of locums' activities before they are left responsible for out of hours care of women in labour.
- The current policy of the East Kent Trust states that it is the responsibility of the healthcare professional who will be supervising the locum to assure themselves of his/her competence. This did not happen in this case. There is at present no requirement for a locum to be assessed on a day shift by a consultant before being left in charge overnight. There is no clear direction that it is the responsibility of the assessing consultant to satisfy themselves of the locum's experience and capability. One specialist from outside the East Kent Trust, X, also stated that it would assist the assessing consultants to be able to see not only the locum's CV but also their references and any training records available.
- The East Kent Trust should consider taking action to ensure that there is a dedicated consultant responsible for reviewing the CVs and references of prospective new locums before they are appointed or employed. A record should be kept of the consultant concerned together with a copy of the consultant's written opinion. The East Kent Trust should also consider making the locum's CV, references and training records (where there are any) routinely available to all consultants with whom the locum will work. Wherever possible a locum should be assessed by a consultant upon a day shift before being left in charge overnight. It is also recommended that the East Kent Trust 10 should consider making it clear that it is the supervising consultant who is at all times responsible for ensuring that the locum working under their supervision is both competent and experienced for the role.
- X had worked two night time shifts at the QEQM before the night of Harry's birth. The extent to which there was any feedback from the consultants on call those two nights to X is unclear. She, erroneously, believed the East Kent Trust had employed X. There is no record of any written feedback. From the evidence of the medical director of the East Kent Trust it appears that the current locum recruitment policy is not being checked or audited. There is a potential for further risks to life arising from these shortfalls.
- Pending any possible review by NHS England and any new guidelines upon the assessment and recruitment of locum doctors it is recommended that the East Kent Trust consider taking action to ensure that consultants who have supervised a locum whether on a day or a night shift should provide written feedback upon the locum's competence and experience to be made available to the relevant HR team at the East Kent Trust and also to any other consultants who may be working with the locum in the future. The East Kent Trust should consider a review of its current procedures as to compliance with policies on the recruitment of new locums, including any new locum recruitment checklist, are being complied with. That review should include 11 consideration of whether there should be a regular audit of compliance. The East Kent Trust should also consider a review of its current procedures relating to the assessment and recruitment of locums to ensure that they meet all current professional guidelines. The East Kent Trust should also review the means by which locums have access to all their policies and procedures including the need for the escalation of care to the consultant, when necessary. There should be consideration of a computer sign in system so that there can be a check that the locum has in fact seen and read the policies.
- There is a risk to the life of both mothers and babies if there is a lack of clarity as to the processes or the need to take prompt action where it is necessitated in the event of an obstetric concern or emergency developing.
- There should be consideration of a review by the East Kent Trust of the obstetric policies, procedures and protocols which relate to the actions which are mandated by the East Kent Trust in the event of a pathological intrapartum CTG including, specifically, those actions which are required, and the relevant time frame, when the 'expedition of delivery' is called for.
- There appeared to be from the evidence given at the inquest substantial confusion amongst staff as to when a consultant should be called at night. The East Kent Trust now has some 70 hours a week consultant attendance on the wards. That leaves 14 hours a day when there is no consultant present. Staff, whether doctors, nurses or midwives should know the circumstances in which consultant help should be sought and should not feel inhibited from making their views known. If staff are unaware or unsure of when the consultant should be called that potentially poses a continuing risk to life.
- The East Kent Trust should consider a review the procedures in place to ensure staff understand the circumstances in which consultant attendance is required and, if necessary, deliver specific training upon this issue.
- The current contracts at the East Kent Trust permit consultants to live up to 30 minutes travel time from the hospital. This poses considerable problems and risks for night time emergencies.
- The East Kent Trust should consider research into any technological solutions which could be found to assist in, or ameliorate, the difficulties of on call consultants living some distance away from the hospital, for instance the use of video link technology or skype connections to the theatres and/or computer terminal readouts from home.
- The evidence of raised substantial concerns about the quality of training and learning in respect of neonatal resuscitation at the East Kent Trust. His evidence was that it would be desirable for middle grade doctors to attend the ARNI course (the advanced resuscitation of the new born infant). He also recommended that there should be simulated drills in neo natal resuscitation.
- The East Kent Trust should consider a review of the current procedures for all relevant staff to attend regular drills and simulation training events covering neo natal resuscitation. The East Kent Trust should consider whether such training should be mandatory and that attendance at such courses is clearly recorded.
- Prior to Harry's death both X, a senior member of staff who had the care of Harry at the William Harvey Hospital, accepted that there were no opportunities for cross site working between QEQM and the William Harvey Hospital. Currently two out of eight middle grade doctors have had the opportunity to spend time at the William Harvey, which has a much higher specification neo natal unit. X described the lack of opportunities before Harry's death as ‘at best, very surprising'.
- The East Kent Trust should review the provision of cross site paediatric working so as to ensure that, where possible, within the next two years all middle grade doctors who aren't on the “run through specialist training programme in paediatrics” have spent a period of time at the level 3 William Harvey Hospital.
- The resuscitation of Harry was eventually carried out by X , the anaesthetist looking after X. His evidence was that leaving his own patient to help the paediatric team was an unusual action to take in the UK although he had often performed such actions in Nepal. Doctors at QEQM indicated that there was an informal policy that if a middle grade paediatrician found themselves in an emergency, they could seek help from their anaesthetic colleagues. It was unclear whether the anaesthetists were aware of this informal policy. This informal policy should be clarified, and guidance given because there is a risk, that in an emergency, it will be overlooked.
- The East Kent Trust should consider a review the circumstances in which anaesthetists are expected to attend and assist neonatal emergencies and to ensure that all relevant members of staff are aware of the policies.
- There appeared to be considerable confusion among members of staff as to which, if any, guidelines and policies affected them. While two senior members of staff, X (consultant), said that the East Kent Trust has systems in place to ensure knowledge of and compliance with Trust policies neither of them was able to say whether this was effective. Significant issues remain as to the knowledge of staff as to which guidelines govern their behaviour (this was also a finding of the Health and Safety Investigation Board in 2019). Such confusion or lack of knowledge increases the risk of future deaths.
- The East Kent Trust should consider a review of obstetric and paediatric staff's awareness of the governing clinical and operational guidance. The East Kent Trust should also consider keeping a register of when and if every member of staff signed off the relevant guidelines as read and understood. This could take place, for instance, at formal training sessions within the unit.
- There was a lack of knowledge within the paediatric team of guidelines issued by the Department of Women's Health. The evidence from the East Kent Trust doctors was that the guidelines issued by the department directed to 'all maternity and neonatal staff who may be involved with the immediate care and support of a collapsed neonate' would not have been known to the paediatric team at the relevant time. Even senior clinicians, such as X, were not aware of the relevant guidelines.
- The East Kent Trust should consider taking action to ensure that the current neonatal resuscitation guidelines are brought to the attention of the neonatology and paediatric teams at the QEQM. Guidelines issued by one department, but which are relevant to staff in a different department should be disseminated and understood by those staff. This could take place during senior management meetings, organised cross department training or electronically with the recipient confirming receipt, reading and understanding of the material.
- The placenta of Harry was not retained. Examination of the placenta will in some circumstances assist in cases of severe foetal distress. The Royal College of Pathologists states that it is 'essential' for the placenta to be sent for examination in cases of severe foetal distress requiring admission to a neo natal unit.
- The East Kent Trust should consider amending its neonatal guidelines to reflect the mandatory nature of the Royal College guidelines to ensure that the placenta is always kept and sent for histology and a record should be kept of each and every such instance.
- The standard of record keeping on the obstetric unit was substantially sub-standard. The quality of the note taking and records is of considerable importance to new staff taking over responsibility for mother and baby. Without there being clear accurate records there is a risk of further mistakes being made leading, at the worst, to the risk of death. An example of this in Harry's case is that the record of the syntocinin prescribed to X over a long period of time is inconsistent with the evidence of the midwives and the registrar who gave it to her.
- The East Kent Trust should consider an audit of the quality of record keeping and documentation and consider whether further training is required so that staff understand the crucial importance of clear and accurate record keeping.
- There are no current records kept by consultants who are telephoned at home for advice. In this case there was a dispute about the number of calls made to X and as to the content of these calls. The advice given and the actions taken as a result are important for the preservation of life.
- The East Kent Trust should consider whether consultants should be asked to keep full records of advice given to junior doctors over the telephone and to time and date them.
- The East Kent Trust should consider a review as to the use or otherwise of a resuscitation pro forma. A pro forma has since Harry's death been adopted by the East Kent Trust which, on the evidence of X, has improved the oversight of neo natal training and governance. It is not clear whether that pro forma is being audited or logged, or what actions are being done to ensure its completion and preservation.
- The East Kent Trust should consider keeping clear records of the use of the pro forma and checking the efficiency of it. The East Kent Trust should also consider whether further training is necessary to ensure the best use of it to prevent further deaths occurring.
- In order to try to prevent future deaths it is important that there are clear records and statements made when a death occurs so that lessons can be learnt. In this instance many of the statements were very scanty in their content and some were made a long time after the event. In some instances, staff had to make statements from memory without the advantage of seeing the medical notes. Contemporaneous (or as near as possible) notes are also very much in the interests of the staff involved so that they can give clear accounts of their actions and reasons for them if required to do so at a later date.
- Where there has been a serious incident staff should be asked to make statements as soon as possible after the event. They should be provided with the medical records to do so. The statements should then be timed and dated and kept in a secure place by a third party.
- The child death notification form was incorrectly completed in that Harry's death was recorded as 'expected'. No notification was made to the Coroner. No details were filled in on the notification form giving any detail of the problems leading to Harry's death. As a result, the Child Death Overview Panel would have been unaware of the problems encountered and could not have shared learning to prevent other such deaths occurring. I make no recommendation in respect of the lack of notification to the Coroner as I am aware that the Senior Coroner has already dealt with this.
- The East Kent Trust should consider a review of its policies so that all staff members who fill in Child Death Notification forms are aware of what to enter into the form and of the details required. All such forms should be logged and audited, including those since Harry's death.
- The MBRRACE form in respect of Harry Richford was inaccurate in a number of important areas. The form is important to provide robust national data to support the delivery of safe, high quality maternal and new born care as well as identifying errors and faults, if any, where there has been a maternal or infant death so that future deaths can be avoided.
- The East Kent Trust should consider a review of all MBRRACE forms filled in since Harry's death were accurately completed and reported. The East Kent Trust should also consider whether it would be advisable to have a second person checking and signing off an MBRRACE form before its submission.
- Important independent reports do not appear to have been shared within the East Kent Trust's staff, for instance the HSIB report into Harry's death appeared during the inquest to be unknown to a number of the staff.
- The East Kent Trust should consider a review of its policies in respect of the sharing of important investigations amongst all relevant staff so that important learning takes place to prevent any future deaths.