Justice is being denied to too many families over baby deaths and the state is colluding in it

Harry Richford had not even been born before the NHS failed him. An inquest has concluded he was neglected by East Kent University Hospitals Trust in yet another maternity scandal to rock the NHS.

His parents and grandparents have fought a tireless campaign against a wall of obfuscation and indifference from the NHS. In their pursuit of the truth they have exposed a maternity service that did not just fail Harry, but may have failed dozens of other families.

As with the family of baby Kate Stanton-Davies at Shrewsbury and Telford Hospitals Trust, or Joshua Titcombe at the University Hospitals of Morecambe Bay Trust, it has taken a family rather than the system to expose what was going wrong.

Bosses at East Kent University Hospitals Trust knew they had a problem. They were warned by a report from the Royal College of Obstetricians and Gynaecologists. As with other examples, they failed to learn or change to prevent mistakes happening.

Harry’s father, Tom Richford, believes that maternity services in the NHS need an overhaul. Based on the conclusions of the inquest into Harry’s death and what we are learning around the country, it’s hard to disagree.

While the Richford family have suffered over the past two years at the hands of the NHS’s instinctive tactics of deny, delay and defend, they have achieved, through their own hard work, some small sense of justice for Harry.

It’s important to remember that many bereaved families never do. Many families in Kent will no doubt be wondering whether they should have asked questions in the way Harry’s unstoppable grandfather Derek did.

We know there were dozens of baby deaths and more than 130 children who suffered brain damage during birth. And those are numbers accepted by the trust. Given Harry’s case and the tactics employed by the trust, we cannot say for certain that there are not more yet to be revealed.

It is known that there are about 1,000 cases a year of safety incidents in the NHS across England, including baby deaths, stillbirths and children left brain damaged by mistakes.

On Wednesday, I attended the first national maternity-safety conference organised by the charity Baby Lifeline, which has joined with The Independent to call on the Department of Health and Social Care (DHSC) to reinstate the axed maternity safety training fund.

This small fund was used to train maternity staff across the country. Despite being shown to be effective, it was inexplicably scrapped after just one year.

Following the scandals at Shrewsbury and Telford Hospitals Trust and now the East Kent University Hospitals Trust, it is imperative that the DHSC and the health secretary, Matt Hancock, commit to bringing back this training.

But there are other issues that need urgent attention. The inquest into Harry’s death, which concluded on Friday, lasted for almost three weeks. Without pro bono lawyers from Advocate, Brick Court Chambers and Arnold & Porter law firm, the family would have faced an uphill struggle.

At present, families are not automatically entitled to legal aid at an inquest, yet the NHS employs its own army of lawyers who attend many inquests and can overwhelm bereaved families in a legal battle they are ill-equipped to fight.

Even the chief coroner, Mark Lucraft QC, has called for this inequality of legal backing to end, but the government has yet to take action.

Justice is being denied to too many families and the state is colluding in this situation by failing to enforce rules, ensure that lessons are learned and, when necessary, that families get answers to their questions.

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