2 Mar 2015

A baby died an avoidable death’: one family’s fight for justice

A report into University Hospitals of Morecambe Bay NHS Foundation Trust is on Tuesday expected to say that as many as 30 mothers and babies died because of poor care.

The report, commissioned by Jeremy Hunt, the health secretary, is also expected to paint a picture of a unit riven with professional rivalries between midwives and doctors, and of a failure of the watchdogs, such as the Care Quality Commission and the Parliamentary and Health Service Ombudsman, to investigate the cases.

And Channel 4 News also understands that NHS England is planning to announce a review into maternity services in England. While the terms of reference have not yet been drawn up it is expected the review will include the safety of the services, including those provided at midwife-led units.

Although the inquiry looks only at Morecambe Bay, it is clear that many of the problems the families faced following the deaths of their babies are far from unique.

We have spoken to one family – 150 miles away – in Ludlow, Shropshire, whose story is remarkably similar. Not least the battle they faced after the death of their baby to have it investigated.

Rhiannon Davies and Richard Stanton’s baby girl, Kate, was born on March 1, 2009 at the Ludlow midwife-led maternity unit. She was cold and floppy but the midwife placed her into a cold cot. It was only after two hours that an ambulance was called. But tragically Kate died after being transferred to another hospital in Birmingham.

Read more: Cynthia Bower – I’m deeply sorry for child deaths

It was later revealed that Kate had suffered from anaemia caused by a ‘substantial fetomaternal haemorrhage’.

Since then Ms Davies and Mr Stanton have had to fight ever step of the way to establish what went wrong, why it went wrong and what is going to change.

Just over two years ago I spoke to them after an inquest jury unanimously found that Kate should not have been delivered at a midwife led unit – that it contributed to her death. This was an inquest that had initially been refused to them. So that was the first hurdle.

I went back to see them again, ahead of Morecambe Bay. And still they are angry. “A baby died an avoidable death – and instead of seeing a failure and trying to cover it up or trying to give an excuse for why that happened, lying, just be honest, be open,” Ms Davies said.

She added: “We felt very strongly after the inquest that everything was in place for it to be resolved. All the evidence was available to the hospital trust to understand exactly what had happened, any inaccuracies or mistakes had been ironed out by the inquest process and it was very very obvious what needed to be done.”

The couple allege failure of care from before the birth until the death. Compounded by Shrewsbury and Telford NHS Trust failing to deal properly with their complaints.

Ms Davies had in the two weeks before the birth complained that her baby was not moving as much. She also complained of feeling unwell. She was checked up and spent three nights in hospital although nothing was identified.

But at this point it would have been normal for there to have been a discussion about whether she should continue with the plan to give birth at a midwife-led unit. There is no evidence that any risk assessment took place.

Since Kate’s death, this is what they have had to do to get to the truth (and it is a far from comprehensive list): Starting with formal complaints to the trust, the West Midlands Ambulance Service and the Nursing and Midwifery Council. Then there was a battle to have an inquest. They then had to persuade the Health Service Ombudsman to look at the case. They’ve been to the police, the health and safety executive and back to the Ombudsman. Finally, in January, the health ombudsman upheld the family’s complaint.

Read more: CQC scandal – Jill Finney denies ‘cover-up’ claim

It shows the ‘midwife did not recognise the seriousness of the situation’. It says: “The records for the baby are of a poor standard and are inaccurate in places…In my opinion the midwife had missed key signs that the baby was unwell. If she had recognised how poorly the baby was earlier then this would have meant that she would have been transferred at an earlier time and she would have been reviewed by a paediatrician.

It is cold comfort to the parents to read that. Because it is clear that Kate would have stood a chance of living if she had been at Shrewsbury hospital where she could have had a blood transfusion.

But where the health ombudsman’s report is most strong is in these paragraphs. “We uphold Ms Davies’ and Mr Stanton’s complaint about the Trust. This is because we found service failure in the care provided for their daughter, Kate, and that Kate’s death was, on the balance of probabilities, avoidable.

“We also found maladministration in the Trust’s handling of their complaint. Ms Davies and Mr Stanton suffered and injustice as a consequence of the failings that we identified.”

So why did it take them so long to get to this point? The Ombudsman tells the Trust to acknowledge the failings and apologise and to review the way it assesses a pregnant woman’s risk.

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Days after the order went out, the trust did apologise unreservedly and ‘acknowledged all the failings identified’ – and said they have taken steps to improve care.

They would not be interviewed by us but in a statement they also said the Ludlow Maternity Unit had been rated as good in a recent CQC inspection. But they added that they deeply regretted the Trust did not write to the couple directly at the time to say sorry.

Ms Davies and Mr Stanton have now complained to the Trust again because of their unanswered concerns that no one has been held accountable for their daughter’s avoidable death, and because of their ongoing concerns relating to the fact that the Trust has yet to put the proper risk assessments in place for pregnant women some six years after Kate’s loss.

Can they ever draw a line under it? “Not yet,” Mr Stanton said. “We have to do what is right for Kate.”

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4 reader comments

  1. Shaun says:

    This is a terrible episode in maternity care and my thoughts are with this couple, it’s difficult to imagine the depth of distress they must feel.
    I do wonder though what more can they be looking for. It’s clear the chain of events was triggered by a poor clinical decision that ultimately resulted in the death of their baby. However, had that clinician accepted they had made a mistake they would have been disciplined and quite possibly have lost their job, despite trying their best. This threat almost certainly contributed to an ill informed decision to change notes, itself a disciplinary matter! A culture of ” seeking justice” or more likely retribution cannot be a way forward. Unlike journalist, clinicians errors can be life threatening and career ending!

  2. Alan says:

    How in any way does this article aid? Completely ignores the underlying factors of the systems drive since 1948 to rid us of the NHS. Completely ignores the profit driven mandate of central government. Completely ignores the administrative quango that trusts have become. In fairness though it does aid government drive to privatisation.

  3. Debbie Pilkington says:

    Sorry trying to find and contact the family from Northern Ireland that were denied Legal Aid to attend these babies inquest. This is absolutely disgusting. Any info at all would be most appreciated. Thankyou. Debbie

  4. Caroline Tully says:

    In March 2014 we lost our daughter, Clara. Her story can be read in this months RCOG Each Baby Counts newsletter.

    https://www.rcog.org.uk/eachbabycounts

    UK Stillbirth rate ranks 33rd out of 35 high income countries in Europe.

    A Coroners Inquest into every Stillbirth where Signs of Life are present during Labour may determine what lessons could be learned from the incidents to improve Patient Safety and provide Answers to families affected. The Inquest I managed to get, although my daughter was originally classed as stillborn, highlighted inadequate risk assessments in my care & was also a factor with 9 other Cases at the hospital.

    We believe the Law needs to be reviewed around coroners jurisdictions in cases of death during labour – https://petition.parliament.uk/petitions/104893

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