Written evidence from Derek Richford

When my grandson died in November 2017 at 7 days old, the NHS Trust told us there was no need to call the coroner as they knew the cause of death, HIE.  Whilst the Trust were investigating what went on we asked again, several times and were told no, we had no idea we could do this ourselves.

After the Trust published their investigation some 4 and a half months after his death, we were so uneasy we reported Harry’s death ourselves, largely out of desperation.  

Our local coroner was most interested but due to the delay and there now being no body, he had to get permission from the Chief Coroner in London, Mark Lucraft.  By the time this came through it was late August 2018.  Harry’s inquest was held in January 2020.

Harry’s inquest was 3 weeks long and was heard as Article 2 and found 7 gross failings with a rider of neglect.  This was the inquest the Trust did not want to happen.  It has transpired since that reporting baby deaths was not something this Trust did regularly at all.

At a point in time around May 2109 the Trust admitted liability for Harry’s death and this then bizarrely meant that our civil solicitor could not represent us in court.  At this stage Article 2 had not been engaged so we faced a huge inquest alone.  The Trust however, used the Head of Clinical Negligence at Clyde and Co to defend their actions/inactions including trying to stop the coroner calling Article 2.

We approached our MP Sir Roger Gale who helped us with an application to ‘Advocate’ the Bar Pro Bono unit.  We were exceptionally fortunate to be granted help.

Only with the exceptional Pro Bono help could we fight for justice to be done at Coroner’s court.  The Pro Bono team secured Article 2 and then had to carry on free of charge as Legal Aid, even if granted, would have meant a change of team and they were not prepared to let us potentially go under represented.

In court, the Trust were fully represented by solicitors and two doctors both had separate barristers. Can you imagine us, the bereaved family representing ourselves against such power?

The general rule is that inquests are not adversarial; this is just not true. The Trust had done everything in its power to avoid scrutiny, falsify documents and withhold information from us, my grandson had died at their hands, this was never going to be a shake hands and see what happened affair.

The trust finally gave us a key witness statement, the Medical Director’s. 3 working days before the inquest and on day 2 of the inquest dumped over 1,000 pages of digital evidence on us that we had been awaiting for months.  We are told this is a common “tactic”.

Trust’s legal teams and solicitors agendas are defend, defend, defend and not about getting to the truth.  We should look carefully at their role and the need for them in this context.

Our coroner produced a PFD with 19 concerns and recommendations.  Imagine that, a lady goes to hospital to have a baby and the coroner find 19 concerns to prevent future deaths.  We understand that the Trust must respond to the coroner but thereafter nothing is checked and there are no obligations.  This has to change, there must be a legal duty for such organisations to comply.

A national coronial service could perhaps allow fo the same coroner to hear all baby death inquests from the same Trust, in this way the same failings will be highlighted quickly.  At the moment there is no one anywhere joining up the rather gruesome dots.

The fact that our Trust were routinely avoiding reporting baby deaths and, in our case telling CDOP that the death was expected and telling MBRRACE that there were no complications at birth meant that Harry’s horrific story could only unfold with months and years of work by me and my family and the good will of our pro bono legal team.

We have to even up the playing field, we have to ensure deaths are reported accurately, remember shipman, what has changed?  Now it seems Trusts can avoid scrutiny unless a determined family choose to fight for two years.

Harry’s case not only ended with a 3-week Article 2 inquest but has also led to the Kirkup inquiry and is a lead case in the consideration of the Health select committee into maternity safety.  Please ask yourselves how such a clearly bad case be hidden from the coronial service and how to stop it ever happening again.

I pay tribute to Brick Court Chamber s and Arnold and Porter our Pro Bono team without whom we would have sunk without trace and also to Coroner Mr Sutton-Mattocks who was excellent.


September 2020