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Baby Harry Richford's Margate hospital death 'wholly avoidable' Baby Harry Richford's Margate hospital death 'wholly avoidable'
(32 minutes later)
The death of a baby seven days after his emergency delivery was "wholly avoidable", a coroner has ruled.The death of a baby seven days after his emergency delivery was "wholly avoidable", a coroner has ruled.
Harry Richford died a week after he was born at Margate's Queen Elizabeth the Queen Mother Hospital (QEQM) in 2017.Harry Richford died a week after he was born at Margate's Queen Elizabeth the Queen Mother Hospital (QEQM) in 2017.
His mother Sarah Richford had been taken to theatre for an emergency delivery after her baby showed signs of distress, the inquest heard. Coroner Christopher Sutton-Mattocks was told Harry was born not crying, pale, and with no movement in an operating room "full of panicking people".
Coroner Christopher Sutton-Mattocks was told Harry was born in an operating room "full of panicking people". Giving a narrative conclusion, he found Harry's death was "contributed to by neglect".
'Harry was failed''Harry was failed'
Giving his conclusion, Mr Sutton-Mattocks said Sarah and Tom Richford had been excited about becoming first-time parents but had been left grieving. Mr Sutton-Mattocks said Sarah and Tom Richford had been excited about becoming first-time parents but had been left grieving.
He said: "They are grieving for a child they believe should not have died. I agree with them.He said: "They are grieving for a child they believe should not have died. I agree with them.
"Mr and Mrs Richford were failed by the hospital, but more importantly Harry was failed.""Mr and Mrs Richford were failed by the hospital, but more importantly Harry was failed."
He criticised the hospital trust for initially saying Harry's death was "expected". Mr Sutton-Mattocks criticised the hospital trust for initially saying Harry's death was "expected", which meant the coroner was not informed of Harry's death.
Mr Sutton-Mattocks said it meant the coroner was not informed of Harry's death and it was only because of the persistence of the family that an inquest was ordered. It was only because of the persistence of the family that an inquest was ordered, the coroner said.
He praised Harry's parents for being "calm and dignified" during the inquest. He praised Harry's parents for being "calm and dignified" during the inquest, and added: "Today Harry should be almost two years and three months old... a bundle of energy.
"Instead his family are still grieving and will do so for the rest of their lives."
'Damage was done'
Harry's mother had been taken to theatre for an emergency delivery after her baby showed signs of distress, the inquest heard.
He was born at 03:32, "to all intents and purposes lifeless".
It took 28 minutes to resuscitate him "by which time the damage was done", the coroner said.
Obstetrics expert Myles Taylor had told the inquest "but for a failure to deliver at 2am" Harry would have been born in good condition and would have survived.
Dr Giles Kendall, a neonatal medicine expert, said that had resuscitations been of an appropriate standard, Harry would almost certainly have survived.
Explaining his conclusion, Mr Sutton-Mattocks said he considered the divergences of unlawful killing or neglect.
"I do not conclude the failures were so large and so atrocious as to fall within the definition of unlawful killing."
He said there were failures by a number of people some of whom lacked the experience for the positions they were in.