The Care Quality Commission (CQC) announced in October 2020 of its intention to prosecute East Kent Hospitals University NHS Foundation Trust following complications which led to the death of a baby in its care.

On 8 October 2020, the CQC charged the Trust with exposing Harry Richford and his mother Sarah Richford to significant harm. Baby Harry tragically died on 9 November 2017, just seven days after he was born on 2 November.

The charges where brought under Regulation 12(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 ('the Regulations').1

The charges

Between the 1st and 2nd of November 2017 at Queen Elizabeth The Queen Mother Hospital, St Peters Road, Margate, Kent, CT9 4AN, East Kent Hospitals University NHS Foundation Trust, being a registered provider within the meaning of the regulations and whilst carrying on a regulated activity, failed to discharge a duty imposed on it by Regulation 12(1) of the Regulations, in that it failed to provide safe care and treatment exposing a service user, namely Sarah Richford and Harry Richford, to a significant risk of avoidable harm whereby East Kent Hospitals University NHS Foundation Trust is guilty of an offence pursuant to Regulation 22(2)(b) of the Regulations and liable to a penalty under Regulation 23 of the Regulations.

- The Care Quality Commission

The 'duty of care'

The 'duty of care' refers to the responsibilities and obligations placed on people to act towards others in a certain way, in accordance with certain standards. The term however, can have a different meaning depending on the legal context.

In principle, the law imposes a duty of care on any health care practitioner in situations where it is reasonably foreseeable that the practitioner may cause harm to patients through their actions or omissions. This applies regardless of whether that practitioner is a doctor, nurse, midwife, health care assistant or assistant practitioner. It exists when the practitioner has assumed some sort of responsibility for the patient’s care. This can be basic personal care or a complex procedure. Case law has established a number of situations where a duty of care will always be owed, such as the case of Cassidy v Ministry of Health.2

Areas of concern

The prosecution of the Trust by the CQC followed an inquest held in 2020, which found that Harry's death was "wholly avoidable and contributed to by neglect" at Margate's Queen Elizabeth the Queen Mother Hospital. Errors found by the Coroner:

  • Hyper stimulation from excessive use of Syntocinon, a drug that speeds up labour
  • Once the Cardiotocography (CTG) heart reading had become pathological by 02:00 Harry should have been delivered within 30 minutes, not 92 minutes.
  • The delivery itself was a difficult one and should have been carried out by a consultant who should have arrived earlier than she did
  • The Locum was inexperienced and was not properly assessed, if at all.
  • Failure to secure Harry’s airway
  • Failure in not requesting consultant support early enough during resuscitation attempts
  • Failure to keep correct account of time keeping and resuscitation attempts

The inquest found there to be more than 12 areas of concern in the care given to Harry and his mother, including the way an "inexperienced" doctor carried out the delivery.

NExt steps

This case is the first of its kind. This is the first time the CQC has prosecuted an NHS Trust over its failings in clinical care. However, this is this sixth time it has charged a Trust with criminal failings. Two of the other cases included a patient falling from a roof at a mental health facility and another focused on the tragic death of a prisoner in Lewes prison, Sussex who was a known suicide risk.

A further post will be made as soon as details of the sentencing are made available.

  1. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
  2. [1951] 2 KB 343

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Ben Munro

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