A coroner has published a list of 19 recommendations following the death of baby Harry Richford at an under-fire NHS trust.
Harry died in a “wholly avoidable” tragedy, seven days after his emergency delivery in November 2017, an inquest found.
East Kent Hospitals University NHS Foundation Trust is under investigation following several baby deaths that are believed to have been preventable.
Last week the Government announced an independent review of the trust’s maternity services as well as placing an independent team of medical experts “at the heart” of the organisation.
In the document published on Monday, coroner Christopher Sutton-Mattocks detailed 19 recommendations in a prevention of future deaths report.
– Reviews at national and local level into how new locum staff are chosen and assessed
– The trust should ensure staff know when a consultant should be called at night, and should investigate how technology can be used to reduce difficulties of on-call consultants living some distance away from the hospital
– The trust should consider a review of procedures for all relevant staff to attend regular drills and simulation training events covering neonatal resuscitation
– A review of policies on the sharing of important investigations among all relevant staff so important learning takes place to prevent future deaths