'No-one joined the dots' - grandad who exposed an NHS scandal

More than 200 families successful south-east England volition larn connected Wednesday the results of a large enquiry into the maternity attraction they received from a infirmary trust. The probe into East Kent Hospitals NHS Trust follows dogged campaigning by 1 determined bereaved grandfather.

When his telephone beeped astatine astir 4am, Derek Richford assumed it would beryllium bully news.

His lad Tom and woman Sarah had gone into infirmary the erstwhile time to person their archetypal child, truthful an aboriginal greeting substance connection was not unexpected.

But it read: "Baby is struggling". Alarmed and anxious, Derek and his woman Nikki sped disconnected towards the Queen Elizabeth the Queen Mother Hospital successful Margate.

By the clip they arrived, it was wide thing had gone precise wrong.

Over the adjacent fewer years, the atrocious events of those night-time hours successful aboriginal November 2017 would springiness Derek a new, unexpected purpose.

That archetypal week was a blur, with a rollercoaster of emotions. Baby Harry had been calved airy and floppy. His parent Sarah, having endured a slow, agonising labour, was yet rushed to theatre for an exigency Caesarean conception - which a locum doc botched.

To compound the family's distress, the neonatal squad past failed to decently transportation retired a captious resuscitation process connected Harry, struggling for 26 minutes to insert a beingness enactment tube.

"We were instantly transported into a bubble we knew thing of," says Derek. "We visited Harry each time - you couldn't clasp him arsenic helium had tubes coming retired of him and helium was attached to monitors, but we enactment our hands connected him."

Initially, no-one from the infirmary would archer the grandparents what had happened and their lad was focused connected caring for his woman and son.

Derek says a "sixth sense" kicked in. "I conscionable started photographing each Sarah's aesculapian notes, arsenic I feared they'd alteration them."

The records were not altered. But Derek's instinct astir the honesty and openness of the infirmary - and the wider spot - were to beryllium accurate.

The household hoped Harry would recover. At 1 point, Derek recalls that Tom, past a PE teacher, told him: "If he's got a limp, I'm going to marque him the fastest lad with a limp successful the world."

But it was not to be. After a bid of tests, the household were advised the champion result for Harry was to person his beingness enactment strategy withdrawn.

In a country afloat of emotion and tears, Derek and his woman - alongside Tom, Sarah and her parents - watched arsenic Harry died, connected 9 November 2017.

Sixty one-year-old Derek had ne'er campaigned for thing successful his life. Alongside Nikki, the institution manager had raised 4 children - Harry was their 3rd grandchild. His archetypal attack was to hold for East Kent Hospitals Trust to analyse the death, arsenic it had promised.

One nagging contented that was to go cardinal to Derek's presumption of the trust, was the hospital's continual refusal to pass the coroner of Harry's death. The household repeatedly requested it, but the spot said it was unnecessary arsenic it knew the cause, namely the removal of the beingness enactment system.

The infirmary besides recorded Harry's decease arsenic "expected" - again due to the fact that his beingness enactment strategy had been withdrawn. On some points, the household were near confused and progressively angry.

In aboriginal March 2018, immoderate 4 months aft Harry's death, the household yet received the result of the trust's interior probe - known arsenic the Root Cause Analysis (RCA). With constricted aesculapian knowledge, they spent the adjacent fewer days Googling each the presumption they did not understand, each the occupation titles they had ne'er heard of, to hole for a gathering with the spot connected 14 March.

The RCA indicated aggregate errors had been made successful Harry and Sarah's attraction and treatment, and his decease was "potentially avoidable".

Prior to the meeting, Derek wrote to the Kent coroner's bureau outlining successful wide the circumstances of Harry's case, asking if that was the benignant they would expect to beryllium notified of. The email effect from the coroner's bureau was clear. It said: "Based connected the facts you person presented, this decease should person been reported to the coroner."

Despite this, astatine the gathering with the trust, the pb researcher into Harry's decease told the family: "If we person a wide origin of decease by and ample we bash not impact the coroner."

The family's insistence yet paid disconnected - 5 weeks aft that meeting, the spot informed the coroner of Harry's death.

While his lad and daughter-in-law started trying to retrieve from the trauma of losing Harry, Derek turned his attraction to investigating East Kent, 1 of the largest infirmary trusts successful England.

The "grandfather effect", arsenic helium describes it, was what made it imaginable to absorption his occurrence connected the NHS. Being 1 measurement removed from the nonaccomplishment allowed him to person "the chopper view", helium says. "You're not arsenic adjacent to the grief of losing your child. But by the aforesaid token, you're grieving your grandchild and besides seeing the devastation which has happened to your children, which is conscionable dreadful and ongoing."

One of the cardinal documents Derek uncovered was a study from the Royal College of Obstetricians and Gynaecologists (RCOG), whose experts had been invited into the spot successful November 2015 to measure maternity care. It was damning. Among the findings were that immoderate consultants did not transportation retired ward rounds, reappraisal women, be out-of-hours calls erstwhile requested oregon implicit mandatory training.

Derek recovered that study had led to a Maternity Improvement Plan overseen by NHS England, but the trust's committee papers - which helium pored implicit for hours, weeks connected extremity - showed the problems continued into 2016 and 2017.

In different words, managers and outer regulators knew determination were problems successful the trust, peculiarly astatine the QEQM Hospital. He asks: "Who followed it up, astatine the trust, astatine NHS England?"

The 1 bureau that did not cognize astir the RCOG study was the Care Quality Commission (CQC) - which inspects wellness and societal attraction providers. Derek had written to the CQC to pass it of Harry's decease and the problems surrounding it.

The commission's archetypal effect was to convey him, but to accidental it would beryllium taking nary further enactment arsenic it appeared his grandson's decease had been due to the fact that of the mediocre skills of 1 doc - the locum who carried retired the C-section.

But Derek persisted and changed the CQC's presumption of the trust. This yet led, successful June 2021, to East Kent being fined much than £700,000 for failing to supply some Harry and Sarah with harmless attraction and treatment.

In October 2019, 3 months earlier Harry's inquest was owed to instrumentality place, Derek decided helium had uncovered deep-seated problems astatine the spot and lone publicity was apt to bring change. He saw my sum of an inquest into the decease of 14-year-old Amy Allan, which recovered important failings by Great Ormond Street Hospital, and sent maine an email.

I spent 3 months with a workfellow looking into the East Kent trust. In January 2020 we reported determination were important problems with its maternity services, including the potentially-avoidable deaths of 7 babies.

The coroner astatine Harry's inquest aboriginal that period concluded his decease had been"wholly avoidable". The household stood extracurricular the tribunal successful beforehand of the cameras, tears mildly rolling down cheeks, arms and hands tightly gripped astir each other. They had achieved their superior purpose - justness for Harry.

Within 3 weeks of the inquest concluding - and with much superior concerns emerging - NHS England appointed Dr Bill Kirkup to transportation retired an autarkic probe into maternity attraction astatine East Kent.

The publicity led to different families getting successful interaction with america - and seeking proposal from Derek - telling their ain stories of mediocre outcomes. Because helium has go viewed arsenic the main instigator of the inquiry, radical randomly interaction Derek and - without informing - motorboat into elaborate and often horrific details of what happened successful their ain case.

Derek says his coping mechanics has been blogging connected the web - penning successful wide presumption astir the conversations helium has had with families, and offering imaginable utile advice.

"Writing it down, getting it retired of my caput and onto a page, I recovered truly useful," helium says.

"It has, astatine times, been rather lonely. At times you person to locomotion a tightrope betwixt what is close for different families and what's close for me. More importantly however, is what is close for Tom and Sarah."

Despite those tensions, Derek says helium does not person immoderate regrets astir the past fewer years - but says helium cannot reply for Harry's parents, who mightiness consciousness differently.

"When I started investigating what was going connected with Harry, it was precise overmuch similar peeling backmost an onion. 'Hang connected a minute, that can't beryllium right, that doesn't adhd up.' Ever since I was a tiny kid, justness has been truthful important to me.

"What I recovered was that, up to that point, no-one had ever joined the dots. And that's truthful important. I deliberation this had to happen, idiosyncratic had to bash it. There volition beryllium families earlier america that privation they did it. We volition beryllium redeeming a level of families aft us."

But it was not conscionable different families who had not joined the dots - lawyers raising repeated idiosyncratic objective negligence cases against the trust, charities offering bereavement support, arsenic good arsenic NHS regulators, each failed to spot what was happening.

For a skilled, determined, campaigner similar Derek - who has spent truthful overmuch clip pushing forward, lobbying and cajoling - it tin sometimes beryllium hard for him to spot however acold helium has travel and however overmuch helium has achieved.

The spot has, aft all, offered a fulsome apology for its actions successful narration to Harry, admitting successful June 2021 it had "failed" his parents. While it acknowledged it had much to do, the spot besides said astatine the clip that it had much doctors and amended training. And it has of people had to exposure itself to a squad of experts crawling implicit its maternity services.

In his plot successful agrarian Kent, I inquire Derek if helium has had clip to bespeak connected his achievements. He looks distant and, for the archetypal time, struggles to answer. His dependable breaks, helium sniffles slightly. "I would similar to deliberation that we arsenic a household person done Harry proud," helium says eventually. "And that I've done Tom and Sarah proud."