Baby Harry Richford was born at East Kent Hospitals University Trust on 2nd November 2017. Due to a catalogue of errors this otherwise healthy baby died seven days later on 9th November 2017. Harry’s grandfather, Derek Richford began a tortuous journey to uncover the truth and hold the Trust to account, in an effort to prevent further harm.

In June 2021 it was reported that following ground-breaking legal action from the Care Quality Commission (CQC) East Kent Trust pleaded guilty to neglect and was fined £733,000. The media attention on this case led to many other parents coming forward and in October 2022 a Bill Kirkup investigation report titled ‘Reading the signals’ was published which examined over 200 maternity cases between 2009 and 2020. The findings were stark.

Had care been given to the nationally recognised standards, the outcome could have been different in nearly half of the 202 cases assessed by the Investigation’s panel. The outcome could have been different in 45 of the 65 baby deaths ­–­ more than two-thirds of cases.

https://www.babylifeline.org.uk/the-east-kent-report-in-summary

Alarmingly, the panel has “not been able to detect any discernible improvement in outcomes or suboptimal care” in the decade between 2009 and 2020

https://www.babylifeline.org.uk/the-east-kent-report-in-summary

There is much written about this case, not least a full account written by Derek Richford on a website dedicated to his grandson called Harry’s Story. Thanks to Mr Richford’s persistence and thoroughly documented analysis, this case provides a clear insight into the difficulties members of the public face when they make an NHS complaint.

Sometime towards the end of the pandemic [no specific date recorded], Derek Richford was a guest on PHSO Radio Ombudsman. The transcript of that recording will be our guide, alongside direct quotes from Harry’s Story. Our focus here is not on the tragic events as they unfolded in the hospital but on the role of the authorities once the complaint was made.

The role of the Trust:

Rob Behrens:  how did the Trust react and work with you and the family in this situation?

Derek Richford: My initial response to that is that they put the shutters up. Let me just run through a few things for you. On the day of Harry’s birth, two consultants, one obstetric, and one paediatric, told us that an RCA would be done. We had to find out what that meant. It was a root-cause analysis. That was on the day that he was born. On the day after he died, so seven, eight days down the line, a post-mortem was arranged. Tom and Sarah said, “When will we talk to the coroner? How does that work?”

Right from that very early point, the day after Harry died, we were told, “Absolutely no need for the coroner. Not the right person to be in touch with. We know the cause of death. There is nothing for the coroner to investigate here.” We were very troubled by this because it didn’t seem right. But, naively, we didn’t know that we could have contacted the coroner ourselves. We’re still in November of ’17 at this point.

In January of ’18, we asked again because we’re getting the results now of the post-mortem and what’s gone on etc. The post-mortem actually says that it can find nothing wrong with Harry. They describe him as, ‘Grossly unremarkable’. Which I found out afterwards meant, “We can’t find anything wrong.” It was repeated in a letter from the neonatal consultant to Tom and Sarah that there is absolutely no need for a coroner involvement.

Eventually we got the RCA report. The RCA report took about 100 days to come through. They kept extending it because they said, “Look, this is a very complex matter. It needs to be dealt with,” and blah, blah, blah. Again, no issue with that whatsoever.

But then it was repeated in the RCA there is no need for the coroner to be called because the family are asking for this and it definitely is not needed. I wrote to the coroner anonymously – it sounds crazy now, but I did – to say “Look, this is the situation. Would you have expected to have been called?” I did this on the Sunday morning. Our meeting was due to be on the Wednesday.

First thing on Monday morning, “Yes, we would like to have known about this death. Where is the baby lying? What happened? How did this happen? Do you have any copies of this, that and the other?” Immediately my heart jumped and raced. I thought, “My god, we should have had the coroner involved.” But we kept our powder dry until the meeting we had on the Wednesday. On the Wednesday we were in front of four consultants, a corporate governance officer, and a midwife coordinator. There were five of us family members, including Tom and Sarah there.

We had a list of questions. We’d stayed up day and night trying to understand what was in the RCA. The medical terms. What grades people were. All these different things. So we had a great number of bits of detail and we wanted to ask lots and lots of questions. We arrived for this meeting on March 14 at 2:00. We actually arrived 20 minutes early as you might imagine. We were met and we were taken to a room that wasn’t ready. We had to help them set up the chairs and the tables, and pass water around the room. It was just awful, really, really awful.

The meeting was recorded, so all of this is something that is able to be looked at now. We actually asked for the meeting to be recorded, and we recorded it ourselves as well. I did that because at that stage I still didn’t trust the Trust. It’s a funny word, isn’t it, trust.

Anyway, we had our meeting. In that meeting it was repeated that you definitely do not need the coroner. There was a 12 minute section where 2 consultants said, “Absolutely don’t need the coroner. You do realise, don’t you, that not all baby deaths are reported to the coroner?” It was said in that sort of tone. I then read out this thing that I’d got from the coroner. I said, “Look, as far as the coroner is concerned, they ought to be told. Look guys, we think you ought to be…” They were reluctant, but they said, “Look, okay.” A lot was said during that three hour meeting. They said, “Okay, we will report it to the coroner.” So, we’d made some ground.

However, it took them five weeks and three days to report it to the coroner after that meeting, and only after we’d chased the Medical Director twice. I cannot to this day fathom how or why that should have been unless, as I’ve said for some time, there is a level of cover-up.

I think it’s only fair to also add to me calling it a cover-up that Harry’s death was reported to the authorities as expected. It wasn’t expected by anyone. In fact, the Trust themselves reported the incident, Harry’s birth, as an unexpected incident internally. But externally they reported it as an expected death. Had they reported it as unexpected, it automatically would have been reported to the coroner. I will also add to that that the MBRRACE report, which is a statutory form that they have to fill out for any baby deaths, brain damage, and maternal deaths, had nine specific errors. By specific errors I mean totally opposite to the truth. Were there any complications at birth? None. Was the placenta kept? Yes. No, it wasn’t. It even says it in the post-mortem that the placenta was asked for, but it wasn’t kept. How did you decide the cause of death? Placental histology. No, you didn’t. You didn’t keep it. So, there is a good number of reasons why I say this.

We worked with the CEO, we worked with the Medical Director over a period of time. By the time we get to the end of 2018 we’re writing back to the CEO to say, “We wrote a complaint to you back in the early part of ’18 and we’ve not had a response. We’ve had an acknowledgement, but no response.” Part of her reply, if I can just quote it, it says, ‘It is understood that we did not log your concerns as a formal complaint at that time, as there was already a root cause analysis investigation in process.’ However, in the RCA itself written ten months before that quote I’ve just given you, ‘The family have submitted a formal letter of complaint. This is being addressed through the serious incident investigation process and through the complaints process.’ It wasn’t, and never was.

If we finish that section, Sir Roger Gale who is the MP for the hospital, a quote from him straight after Harry’s inquest was, “I believe that in the early stages, the hospital authorities were obstructive in their efforts to prevent the facts from being established. What should have been a straightforward process therefore contributed to the family’s ordeal.” I think that probably is enough for me to give you a flavour.

Summary: The Trust was automatically obstructive, using misinformation, delay and outright lies to prevent the facts from coming to light. The modus operandi was damage limitation, relying on the fact that members of the public are ill-informed, unsupported and often too traumatised to stay the course.

The role of the Regulators:

Rob Behrens: As a family member, what is your view of the regulation, and the coordination of regulation in the Health Service?

Derek Richford: You’ve asked me about regulators. Frankly, there are too many regulators and they’re all working in their own silos. There is absolutely no doubt in my mind that there needs to be radical, radical change. We have had to work with so many people. The CQC, the coroner, HSIB, the CCGs, GMC, NMC, NHS England, NHS Resolution, the police, Kirkup, our MP and of course, your good selves at PHSO. That’s just to give you a flavour.

If we then say, “Okay, we’ve got too many regulators, let’s see how they actually work.” Because I reported this to the CQC within days of Harry’s death. Really, just to highlight it. It was on the standard form on their website and you get a standard response back. Understandably. I then followed the standard response back to say, “Look, actually I’ve uncovered a few more bits here. There’s a bit more concern here.” And so on.

I want to say this really carefully because to me, I still don’t understand it. I cannot understand it. August of 18, 9 months after it’s been reported to the CQC, we have an email that says, ‘We have held three management meetings to discuss the information shared by yourself and the Trust, including the RCA, both independent reviews, the Trust’s action plan, and additional information requested from the Trust. After an extensive review, we do not believe there has been a breach in regulation. The concerns raised in this incident are centred on an individual’s decision, or error. The criminal offences CQC can prosecute against only apply to registered person failures. The action taken by the Trust to date, in line with the recommendations by the independent reviews, suggest the previous risks have been mitigated. Evidence for this includes the introduction of safety huddles, a consultant handover form, additional staff training, improved recruitment processes and new guidance on difficult intubation.’

We got that, and I read it with disbelief. I replied very nicely and said, ‘Thank you so much for looking into this matter, but I believe you’ve missed this, this, this and this. I hope you don’t mind, but because you’ve exhausted what you’re doing, I’ve copied in Professor Ted Baker, head of CQC hospitals.’

It was only then that we started to get traction. What I would say to you Rob, is how did we get from that email which is absolutely cutting us adrift and saying, ‘There is nothing for the CQC here.’ To having the biggest criminal prosecution against a Trust that the CQC have ever carried out? I’m not trying to be big-headed, this is not about that at all, but without me, that would not have happened. It just seems so, so wrong.

Summary: The CQC took nine months to determine that there had been no breaches in regulation and accepted the word of the Trust that all issues raised in this case had been mitigated. We now know that both of these assumptions have proven to be false.

The role of PHSO:

Rob Behrens:  I’m not going to sit here and criticise other institutions because I know that your experience with PHSO was not ideal, and that’s putting it mildly. Tell us about your experience with the Ombudsman service.

Derek Richford: Okay. I’ve already mentioned that were in touch with our MP, Sir Roger Gale, who was extremely helpful. He was in touch with the health minister and at the time, I can’t remember who it was now, wrote back and said, ‘You need to be in touch with PHSO. They’re the people that should be looking into your complaint.’ No one at that stage realised quite how bad things were other than the family.

I rang PHSO on 6 December 2018 and I was given a C number, a case number. Went through the case and was told, “You haven’t got an inquest date yet. When you get an inquest date call us back.” So it wasn’t until November ’19 when I knew that the inquest was definitely happening in the January of 2020, that I called back and spoke to a young lady who said, “Oh no, you need to be putting a formal complaint in now. This seems quite urgent.”

Okay, so I filled out the forms as you fill them out. Even today, I don’t believe that anyone at PHSO, except perhaps yourself Rob, knows Harry’s story back to front and knows all the intricacies of what’s gone on. The letters that have gone back, the lack of investigation by the Trust, and so on, and so forth.

I think that we were largely cut adrift because, and this is not just PHSO, all of the regulators, and by regulators let’s include people that are not necessarily regulators, but they’re involved in what we’re doing. These people, all of them, spend far more time worrying about treading on each other’s toes and not getting into each other’s patches. They spend an inordinate amount of time doing that.

From a PHSO point of view, I think that you were far more interested in, “Ah, hang on a minute.” I had conversations with your staff, as you know, that said, “Oh, could you just clarify exactly what it is you’d like PHSO to look at? We only look at certain things.” It was almost a matter of, “Unless he can get it on the bullseye, we’re not going to be looking.” There were more reasons not to look than there would be to look.

I’d done my research, I think you’re used to that now. I knew that you would look at the complaint part of how the Trust handled the complaint, and I was pushing everything in that direction. Then as it got towards, I guess we’re now looking at towards the end of 2020, the decision was made, “Actually, Kirkup is doing that job. We don’t need to do it. Thanks very much.” And off we trot.

Now, that’s harsh. And I don’t mean to be harsh. But you, as an organisation, had the opportunity to engage with us from 8 December 2018. You had the opportunity to engage with us further in November 2019. Kirkup wasn’t put into place until six months after that second contact with your people. It felt to us all the way through as though actually, you’d rather not. You didn’t really have the resources necessarily to be able to look at such a big case.

I would have loved to have had an hour on the telephone with someone to say, “Look, can you just listen to this whole case from start to finish, and then make your decision?” Don’t make me decide what I’ve got to complain about because that doesn’t feel right. I’m not going to go to into Tesco and say, “Oh, could I speak to you about this piece of meat that’s gone wrong?” And they say, “No, I’m awfully sorry, I only deal with biscuits, sir. Find someone else.”

Summary: The response of the Ombudsman is to find various reasons to delay investigation. Initially, PHSO say that the complaint is ‘not ready’ for them causing a year’s delay. On follow-up, they apply a narrow remit apparently in an attempt to avoid investigation. Finally, with a delay of two years from initial contact, they pass the baton to Bill Kirkup.

Up to this point, the Richford family had been failed by the Trust, who investigated themselves and lied in order to avoid referral to the Coroner. Failed by the CQC, who found no breaches and closed its investigation. Then failed by the Ombudsman who found one excuse after another not to investigate. The breakthrough for this family came from the opportunity to have an independent investigation from the newly formed Healthcare Safety Investigation Branch (HSIB)

HSIB became functional in April 2017 with a specific focus on maternity care. to start in April 2018. Here is Derek’s transcript from ‘Harry’s Story.’

We approached the Healthcare Safety Investigation Branch in Early April 2018 soon after the meeting we had with the Trust. It was at this time, we were all crystal clear that there were major issues to be looked at. It took two months of emails, phone calls and providing detailed information to them in order to get an investigation.  Harry was born too early for their statutory maternity investigations as these only applied to to babies born from April 2018, so we were given a national learning investigation to look at themes that could be learnt nationally. 

HSIB investigated and interviewed for 6 months and then published their report to the family and the Trust in January of 2019.  This is an organisation that does not attribute blame, so their report into Harry’s case may surprise you.

http://harrysstory.co.uk/hsib-involvement.html

The final report was damning. “The HSIB summary report highlights that from July 2018 to January 2020 HSIB commenced 24 investigations with East Kent, and from December 2018 engaged frequently with the Trust to present evidence of recurrent patient safety concerns in its maternity services. Despite repeatedly raising these concerns with the Trust, HSIB investigators continued to see the same themes reoccurring and in August 2019, asked the Trust to self-refer themselves to their clinical commissioning group (CCG) and the Care Quality Commission (CQC).”

With this report, the family had independent evidence to support their concerns and CQC finally investigated their complaint, 22 months after Harry’s death.

To make the point, August 2019, when HSIB were exceptionally concerned as above, was 22 months after Harry’s death, and 6 months before the conclusion of Harry’s inquest. It was at this time the CQC went in and inspected, only to find significant failings were still very evident. It seems that maternity services were still unsafe for all of this time.

“Denial is the biggest factor in the failure to learn” – Harry’s grandfather Derek

http://harrysstory.co.uk/hsib-involvement.html

The Richford family was initially shut down by the CQC with the ‘nothing to see here’ message. They also suffered endless delays at the hands of the Ombudsman. Neither of these bodies seriously attempted to uncover the scandal at the East Kent Trust and neither of them prevented further harm from occurring in a timely manner. It was the new kid on the block, Keith Conradi with a background in aviation investigation at the Air Accidents Investigation Branch (AAIB) who uncovered the truth. The actions of HSIB, under Conradi’s leadership, prevented the Trust from covering up the harm caused to so many families and led the way in forging improvements in patient safety.

It would appear that Bernard Jenkin as chair of PASC then PACAC was right to push for a new, independent healthcare investigation body in an effort to improve patient safety, but all was not well with the new organisation and ‘bad news’ began to leak out to the press.

In April 2018 a story broke which focused on Keith Conradi personally.

Patient safety chief insisted the £562 taxpayer-billed helicopter lesson in the Cotswolds was crucial for his job

  • Keith Conradi flew a lightweight helicopter over the Cotswold Hills for a day
  • The training came at a cost of £562 and helped him retain his helicopter license
  • He claimed this was necessary for his NHS role, as chief investigator at the Healthcare Safety Investigations Branch

Then in June 2019, seven whistleblowers spoke out to the Health Service Journal about poor governance and culture at HSIB.

Poor governance and cultural problems at the Healthcare Safety Investigation
Branch have damaged staff morale and led to confused decision making
according to multiple whistleblowers, who told HSJ it had also seen major
delays to its reports and needed to be “put back on track”.

https://minhalexander.files.wordpress.com/2019/09/hsib-safety-watchdog-hit-by-poor-governance-and-culture-.pdf

By November 2021 Keith Conradi announced his retirement. In a farewell interview with Roy Lilley in July 2022 Conradi got a few things off his chest with regard to his frustrating relationship with NHS England.

He is due to retire as HSIB’s Chief Investigator this month. His quoted frustration about top level NHS leaders’ failure to engage with HSIB in its important role as watchdog for patient safety should provide a wake-up call to the NHS and the Department of Health and Social Care. Despite countless public inquiries, national ambitions to reduce harm and improve patient safety, and much political rhetoric, it seems that even at the highest level, NHS remains unwilling or unable to learn from its mistakes.

https://www.boyesturnerclaims.com/news/patient-safety-hsibs-chief-investigator-says-nhs-englands-priorities-are-elsewhere

Conradi came from a background where cover-up would harm not only the public but the staff. He was not equipped in the art of wilful blindness but was a man seeking the truth. It would appear that he had a fractious relationship with NHS England throughout his tenure. Were the ‘leaks’ orchestrated to reign him in?

In any event, on his departure, HSIB was reformulated as the Health Services Safety Investigation Body (HSSIB) with a new chair and no further remit to investigate maternity cases. The political appointment of Dr. Ted Baker will tell you all you need to know about the likely performance of the new body.

Dr Baker will be the first Chair of the new organisation when it becomes an arm’s length body (ALB) in April 2023. Dr Baker is a retired consultant paediatric cardiologist, and most recently was Chief Inspector of Hospitals at the Care Quality Commission (CQC) between 2017 and 2022.

https://www.hsib.org.uk/news-and-events/new-chair-of-the-hssib-formally-appointed/

The new chair of HSSIB was Chief Inspector at the CQC at the time the Richford family was closed down by the wholly inadequate investigation into their initial complaint. Ted Baker would have been instrumental in that decision. He is joined by Mike Durkin as the newly appointed non-executive director who has been overseeing public health scandals for many years.

Dr Mike Durkin one of our [NHS Resolution] Associate Non-executive Directors. Prior to this appointment he was NHS National Director of Patient Safety at NHS Improvement and before that the Medical Director of the South of England Strategic Health Authority. He has also held Executive Medical Director positions at a Strategic Authority and at Gloucestershire Royal Hospital.

https://resolution.nhs.uk/leadership/mike-durkin/

Ted Baker, Chair Designate of HSSIB, says: “We are pleased that the non-executive directors have now been announced – it is an important step in our journey to becoming HSSIB. Those appointed into the roles come from a range of impressive backgrounds, bringing a wealth of expertise and substantial experience serving on national Boards.

https://www.hsib.org.uk/news-and-events/non-executive-directors-for-hssib-board-announced/

Conclusion:

The only body to take proper action and uncover the truth in the Richford’s case has now been transformed by the government to be run by experienced NHS stooges grandees with no remit to investigate maternity care. The route taken by the Richford’s to expose dangerously poor maternity care has been closed.

In the fullness of time expect the likes of Rob Behrens, Bill Kirkup, Ted Baker or Mike Durkin to scratch their heads as they try to articulate why it is that the NHS never seems to learn from past mistakes.

#corruptbydesign