The Battle Against Nothing to See Here

On November 2nd, 2017, I was transported instantly from the bubble I call my life, to a completely different bubble. My new, hugely unwelcome bubble happened when my grandson Harry was born at East Kent hospitals and made extremely unwell by abstract poor care. The new bubble demanded completely different priorities, different emotions and was totally alien to me and those around me. The details behind what happened to Harry can be found here at harrysstory.co.uk. However, today I want to explore some aspects of how complaints were handled for us.

The Battle against “Nothing to See Here”

When Harry died on November 9th, 2017 at just 7 days old, we all wanted answers as to why so much had gone wrong. After all, Harry was a low-risk birth where all involved expected a perfect outcome.

The Trust agreed to a Root Cause Analysis investigation (RCA), so we let them get on with that. We reported Harry’s death to the CQC and they replied with a “thank you, this information will be used in our inspections” but nothing else. The RCA was due to be completed within 60 days, so we started to chase in the new year of 2018. We were told that it was complex, and that they needed more time. It took until March 6th before we were sent the RCA, and a meeting was arranged for March 14th at 2pm. The RCA was sent to us in hard copy, not digitally, so we had to scan it and share it between the family in that way.

By the time we got to March 14th, we had 5 pages of questions and had very little sleep since the 6th while we googled medical terms and understood for ourselves what had happened. The meeting was attended by 5 of us and on their side, 4 consultants, a midwife coordinator, and a corporate governance officer who chaired the meeting. One consultant was 10 minutes late in arriving, another over an hour late and we had to start without him.

Our key point at that time was “Why won’t you refer Harry’s case to the coroner?”. The meeting meandered for 3 and a half hours. And was, at our request, recorded. We got through our questions and realised that labour, delivery and resuscitation were all completely flawed. At one point in the meeting the Chair, who was not clinical, said yes, Harry’s death was avoidable and one of the consultants agreed to report it to the coroner. However, it took a further 5 weeks and 3 days to do so, and only after we chased the Medical Director twice. The Trust were in total denial of any issues in maternity.

We spent the next 2 years successfully pulling apart everything they had told us.

We reported all we found to the CQC, and in August 2018, we had a “final” email from them to say that our complaint centred around one doctor making a mistake. This was clearly wrong, based on all of the evidence we had seen. A long and arduous trail of emails and meetings where we had to travel to London at our cost to see them eventually resulted in the first-ever criminal prosecution of a Trust for unsafe care and treatment. The Trust pleaded guilty and were fined £733,000 net after discount.

We reported Harry’s death to the Health Service Ombudsman. We were given a case number but despite many many chases, they did nothing. Eventually, Bill Kirkup was asked to investigate the Trust, and Rob Behrens the Ombudsman wrote to me to say that Bill and his team would do a better job of investigating, so we will leave him to do it rather than PHSO. This was 2 years after we had reported Harry’s case to them.

We reported Harry’s death to the coroner ourselves, 5 weeks before the Trust did. The Trust solicitors did all they could to push back on the idea that it should be an Article 2 inquest. We had 5 separate harrowing pre-inquest reviews. Eventually, on January 6th, 2020 Harry had a 3-week Article 2 inquest where the coroner concluded 7 gross failing amounting to neglect.

We reported the consultant to the GMC as she had failed to attend Harry’s birth, leaving a Locum Registrar who had never worked unsupervised before in charge overnight. By this time, the GMC had already found that the Locum had failed and he was given 13 undertakings. Their investigation into the locum pointed directly to the consultant being at fault.

After a protracted investigation, the GMC found that the consultant was not fit for practice on the night of Harry’s birth. However, as she had an unblemished history, and had reflected, they did nothing, not even a warning.

We reported the midwives concerned to the NMC. At the time of writing, one midwife is facing an FTP tribunal in December 2023 and they are still deciding what to do with another. 6 years on and still no resolution.

There were others including the Kirkup, police, solicitors, MPs and PALs but all had to have meetings, separate investigations, and required us to re-tell our story in the greatest of detail, again and again and again. This as a process was unbelievably harming. Why is it the harmed family who always have to battle? Why isn’t someone like the CQC taking this on for families?

Our battle turned into a crusade, and we are only just getting back into the bubble we knew as our “normal” back in 2017. We have achieved a great deal. The CQC are now inspecting maternity services properly and uncovering horrors all over the country. The narrative at NHS England around maternity is now about listening and family involvement and here in East Kent, where I still assist them to get better, still births and neonatal deaths are below national averages. There is still so much to do, but please, let’s not leave it to families to make a difference, there are plenty of NHS staff to do so.