The case of baby Harry Richford, who died in 2017, was instrumental in deeper investigations being made into the standard of East Kent maternity care.
Harry was born in a hospital in Margate in an emergency delivery. He was transferred to the intensive neonatal unit at William Harvey Hospital in Ashford, but later died.
The Trust insisted a coroner did not need to be informed of his death and that an inquest was not required.
However, Harry’s family contested this, and secured an inquest having contacted the coroner directly themselves.
During the inquest, more than a dozen areas of concern were highlighted over the care of Harry and his mother, including failings in the way an ‘inexperienced’ doctor carried out the delivery, followed by delays in resuscitation.
The coroner found Harry’s death was contributed to by neglect. He had died seven days after his delivery from a condition caused by a lack of oxygen.
An independent report said he might have survived had there not been a delay in resuscitation at his birth that caused irreversible brain damage. The case prompted the review which has now taken place, commissioned by NHS England and NHS Improvement. In June 2021 the Trust was fined £733,000 for failures following a Care Quality Commission (CQC) prosecution.