Harry Richford inquest: 'Lives at risk' over locum doctor recruitment
Lives may be at risk unless the NHS reviews how stand-in doctors are recruited, a coroner has warned.
An inquest heard he was delivered by an "inexperienced" locum doctor who was new to the hospital.
A national review into the recruitment, assessment and supervision of locums should be carried out, Christopher Sutton-Mattocks said in a report.
The coroner wrote that particular emphasis should be considered upon the scope of locums' activities before they are left responsible for out-of-hours labour care.
He issued 19 recommendations to prevent future deaths, including a request that NHS England and the Royal College of Obstetricians and Gynaecologists consider such a review, warning "there may be a risk to other lives both at this trust and at other trusts in the future".
East Kent NHS Trust came under scrutiny after the inquest, in which Mr Sutton-Mattocks found more than a dozen areas of concern.
An independent review will be held into maternity services at the trust after it was found up to 15 babies died there in recent years.
The nationwide review should look at whether locums should be "left responsible for out of hours care of women in labour", Mr Sutton-Mattocks wrote.
He said locum registrar Christos Spyroulis, who was in charge of delivering Harry on his third night at the hospital, appeared not to have had "any assessment of his skills and abilities or any supervision" after being hired.
Failings in the way Harry was delivered led Myles Taylor, a consultant obstetrician and gynaecologist, to conclude that Dr Spyroulis was "inexperienced," the coroner found.
'Fully and swiftly'
The inquest found these failings were followed by delays in resuscitation, led by another doctor.
Expert evidence "raises concerns that there may be a risk to other lives both at this trust and at other trusts in the future," said Mr Sutton-Mattocks.
The majority of his recommendations were directed at East Kent NHS Trust, which said it accepted all the suggestions and had appointed a team lead by an external senior clinician to implement them "fully and swiftly".
Locum doctors are now assessed before being left in charge overnight, the BBC understands.
The Royal College said it is considering the coroner's recommendations and is already working with NHS England to improve maternity services at the trust.
NHS England said Dr Bill Kirkup, who is leading the review of East Kent's maternity services, would also "consider what wider regulatory or practice changes are needed to guarantee safe services at any other maternity units where concerns may arise".