The parents of a baby who died in a midwife-led maternity unit have called for improvements after an inquest jury found she would probably have survived at a hospital with obstetricians.
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Kate Stanton-Davies died just six hours after she was born. On Friday the jury unanimously found that she should have been categorised as high risk and not sent to Ludlow Community Hospital in Shropshire. Asked whether being delivered at Ludlow contributed to her death, the jury said yes.
Her parents, Rhiannon Davies and Richard Stanton, of Ludlow, fought for three years and eight months to have the jury inquest.
They are highly critical of the care they received by Shrewsbury and Telford NHS Trust and they want safeguards put in place to ensure midwife-led units are safe.
By the time Kate got to me she was virtually dead. There was nothing I could do to save her. - Dr Alison Bedford-Russell
In the two weeks before Kate was born, Rhiannon had been seen several times by midwives because of her concerns that something was wrong with her unborn baby. She was admitted to hospital to twice.
Experts at the inquest said this should have meant Ms Davies was categorised as high risk and not sent to Ludlow.
When Kate was born in 2009, she was cold and floppy. But at the inquest, the midwife admitted that she left Kate in a hypothermic state in a cold cot for a prolonged period of time while she went about other tasks.
Nobody knows when Kate collapsed but it took two hours from her birth for an ambulance to be called. An air ambulance was sent, leaving Kate's parents behind.
It was initially headed for Shrewsbury hospital but learned the helipad was closed. The doctor on board then suggested Birmingham Children's Hospital, unaware that it did not have a neonatal unit. It finally went to Birmingham Heartlands.
Before the flight two attempts to put a breathing tube in failed because they were kinked from being badly stored. When Kate arrived at the hospital, there was just a pink slip with the mother's name and Kate's birth weight.
I have spoken to the consultant who was on duty. Dr Alison Bedford-Russell said the transport arrangements were chaotic. She did not know where the parents were.
"I was angry," Dr Bedford-Russell said. "By the time Kate got to me she was virtually dead. There was nothing I could do to save her."
To compound this, Rhiannon and Richard were travelling by car, frantically making calls to find out where their daughter had gone. But Rhiannon collapsed and had to be taken to hospital.
Richard arrived in time to hold Kate as she died. Rhiannon did not make it in time. She said to the inquest: "I was met by a nurse. I said, 'she's dead, isn't she?,' because I just felt that she had gone, and the nurse just nodded. I collapsed."
Kate had suffered a rare complication which led to haemorrhage in the womb. A pathologist told the inquest that Kate was extremely anaemic. But this could have been corrected by a transfusion in the womb or immediately after she was delivered.
"Taking time to reflect"
West Midlands Air Ambulance Service said that tragically the evidence showed that Kate could not have survived by the time the ambulance was called. The trust involved said it was 'taking time to reflect' on the jury's decision.
But Dr Bedford-Russell said midwives must be educated to recognise the abnormal. Meetings have already been set up with midwives from Scotland to discuss rural midwifery and the difficulties of having longer and further to travel if something does go wrong.
There is a push both by the government and the Royal College of Midwives to promote midwife-led centres. But Kate's parents believe they should provide ante-natal and post-natal care but not be used for deliveries.
15 November 2012
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