Morecambe Bay inquiry chief voices criticisms over East Kent hospital scandal

‘When there is sufficient concern about a service to prompt an external review, the report must be available immediately to those responsible for assuring the quality of the service,’ says Bill Kirkup

Harry Richford’s death at Queen Elizabeth The Queen Mother Hospital was ruled to have been 'contributed to by neglect' and 'wholly avoidable' (Alamy)

The failure to pass a damning report about a scandal-hit hospital trust to the care watchdog has been criticised by the man who led the inquiry into baby deaths at Morecambe Bay.

On Friday, a coroner ruled that the death of baby Harry Richford in 2017 resulted from neglect in the maternity unit of East Kent Hospitals NHS Trust.

A report by the Royal College of Obstetrics and Gynaecologists (RCOG) completed a year earlier had warned of issues that contributed to Harry’s death, including senior doctors not showing up for their shifts.

However, the report was never passed on to the Care Quality Commission (CQC), despite the recommendation of the Morecambe Bay inquiry in 2015 that relevant external reviews should be passed on to the watchdog.

Bill Kirkup, who chaired the inquiry into deaths of mothers and babies at Furness General Hospital in Barrow-in-Furness, told The Independent: “When there is sufficient concern about a service to prompt an external review, the report must be available immediately to those responsible for assuring the quality of the service. That was the reason for the recommendation of the Morecambe Bay investigation, and it is disappointing that the Care Quality Commission apparently had no sight of this report until now.”

Harry’s death has now sparked a criminal investigation by the CQC. He was left with brain damage after being deprived of oxygen during delivery, following a series of errors by panicking doctors and midwives.

Assistant coroner Christopher Sutton-Mattocks ruled that Harry’s death was “contributed to by neglect” and “wholly avoidable”, although he stopped short of concluding that it amounted to unlawful killing.

Harry’s mother, Sarah, said that the RCOG report “literally, word for word, says exactly what happened to Harry”.

East Kent Hospitals Trust said that it had made a number of changes to its maternity services following Harry’s death at Queen Elizabeth The Queen Mother Hospital in Margate, including the way it monitors babies’ heart rates during labour; recruitment and supervision of locum doctors; and staff training.

Paul Stevens, the trust’s medical director, said it fully accepted the coroner’s findings and was “deeply sorry” for “the devastating loss of baby Harry”.

A CQC spokesperson said: “CQC was aware of the Royal College of Obstetricians and Gynaecologists (RCOG) report. The trust informed us that they had commissioned a review of their maternity services in 2015, and shared information about the actions being taken forward in response to the RCOG’s findings prior to our September 2016 inspection, and after that inspection as part of their improvement plan. However, our records do not indicate that we received the full report before January 2019.

“CQC’s 2016 inspection rated maternity services as ‘Requires Improvement’, identifying that staffing levels were impacting on the quality of patient care. That rating remained unchanged at our 2018 inspection, during which it was noted that the department had changed its approach to foetal monitoring training after concerns were identified.

“The trust remains subject to close monitoring and further inspections.”