10 Dec 2020

Maternity scandal: the battle for justice

On March 1, 2009 Kate Stanton-Davies died. She had lived for just six hours.

Kate was born at a midwife-led unit in Ludlow, part of Shrewsbury and Telford NHS Trust.

More than three years after her death, I met her parents, Rhiannon Davies and Richard Stanton. An inquest, which they had at first been denied, had finally returned its verdict.

“Seven men and two women sat there and listened to eight days of harrowing detail of Kate’s last two weeks of life and the six hours that she was with us – and came to the unanimous decision that there were drastic errors at all levels that could have been avoided, should have been avoided, and contributed to the death of Kate,” Richard Stanton told Channel 4 News.

These are the facts: in the weeks before the birth, Rhiannon had complained about a lack of movement.  Despite repeated check-ups and tests she was not classified as high risk and sent to the hospital, rather than the midwife-led centre.  When Kate was born, she was floppy and pale. She began to grunt, which is a sign of respiratory distress. But she was left in a cold cot and not checked on.

An ambulance was eventually called but wouldn’t take the parents. Eventually Kate was taken by air ambulance to Heartlands hospital in Birmingham. Richard and Rhiannon had to make their own way, but Rhiannon became ill and had to be taken to another hospital. Richard arrived just in time to hold their baby as she died.

I am not ashamed to say that both I and the cameraman wept as we listened to their story. A death of a baby – their first born – is heart-breaking enough. But the way they were treated subsequently, and the battles they have had to fight to prove their Kate should have lived, is beyond description in its inhumanity and cruelty.

Their first battle, indeed, was having to threaten a judicial review if they were not allowed the inquest. That over, however, and the confirmation she shouldn’t have died, you would have thought they could have begun the process of mourning. Instead, they were denied an acknowledgement from the NHS trust – and from those involved that they held responsibility for what went wrong.

There is not enough room now to detail all the fights that have followed – not just with the trust, though that deserves a whole chapter on its own, but also with the health ombudsman’s office, the Nursing and Midwifery Council, the CQC, the General Medical Council, NHS England…  it goes on and on.

But, more than 11 years later, a review into maternity care at the Shrewsbury trust has published its initial findings and it makes for very difficult reading.

Led by former midwife, Donna Ockenden, it started with Kate Stanton-Davies and Pippa Griffiths, who died in 2016, and 21 other families.

Today, the review reports on 250 cases. But they have already spoken to 800 families, and altogether the number of baby and mother deaths and injuries they have been asked to examine has reached 1,862.

It will be the largest maternity review ever in the history of the NHS.  A scandal of proportions that defy belief.

“Kate’s death in 2009 and Pippa’s death in 2016 were avoidable. The parent’s unrelenting commitment to ensuring their daughters’ lives were not lost in vain continues to be remarkable,” Donna Ockenden writes.  “In a void described by the families as ‘incomprehensible pain’, they undertook their own investigations to highlight the deaths of their newborn daughters, and to insist upon meaningful change in maternity services that could save other lives.”

And that is what hurts Rhiannon and Richard so much. Their fight did not stop other deaths, of babies and mothers, of babies being left disabled for life, of families destroyed, of psychological harm that can never be undone.

Now, the trust and all maternity units in England have been told they must improve. The Ockenden review states: “With a focus on safety, the 27 local actions for learning and seven immediate and essential actions in this report are ‘must dos’ that need to be implemented now at pace.”


Photo credit: Richard Stanton

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