Harry Richford died a week after he was born at Margate’s Queen Elizabeth the Queen Mother Hospital (QEQM) in 2017.
Coroner Christopher Sutton-Mattocks was told Harry was born not crying, pale, and with no movement in an operating room “full of panicking people“.
Giving a narrative conclusion, he found Harry’s death was “contributed to by neglect”.
Dr Paul Stevens, medical director for East Kent Hospitals NHS Trust, said: “We are deeply sorry and wholeheartedly apologise for our failings in Harry’s care and accept the coroner’s conclusion and findings.”
‘Harry was failed’
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.
“Mr and Mrs Richford were failed by the hospital, but more importantly Harry was failed.”
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.
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, 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’
Mrs Richford had gone to the midwifery-led unit at QEQM on 31 October 2017. Twenty hours later she was moved to the labour ward and given a drug to speed up labour.
At 01:30 GMT on 2 November, concerns were raised about Harry’s heartbeat.
Three midwives and a senior doctor recalled how it kept dropping and how there were concerns over his position before he was born.
At 02:05 it was decided the baby needed to be delivered, but it was not until an hour later that locum registrar Dr Christos Spyroulis began an attempt to do so using forceps.
Harry 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.