MY BABY WAS VICTIM OF CARE SCANDAL
The devastated parents who helped unearth what is likely to be the NHS’s worst ever baby care scandal
BABY Kate Stanton-Davies was barely six hours old when she died in her heartbroken father’s arms.
The child had been born floppy, pale and cold to the touch despite assurances from NHS staff that she had been healthy throughout the pregnancy.
Despite being flown by air ambulance from a midwifery-led unit to a specialist neonatal unit, it was too late to save her.
“It went from being the most ecstatic moment in my life, filled with overwhelming joy, to the deepest, darkest place you could imagine,” said Kate’s dad Richard Stanton, recalling the horrendous turn of events of March 1, 2009.
“We knew things had gone wrong and we immediately began to ask questions.”
Still struggling with overwhelming grief, Richard and wife Rhiannon Davies embarked on attempting to uncover what had gone wrong in Kate’s care.
After threatening a coroner with a judicial review, an inquest was finally held in November 2012 where a jury found that staff at Shrewsbury and Telford Hospital NHS Trust were at fault for the baby’s death.
The midwife responsible for Kate’s care was also struck off, but many years later.
“Kate’s death was avoidable. She should be with us now,” added Richard. “In the last two weeks of the pregnancy Rhiannon said to staff at the Royal Shrewsbury Hospital that she was experiencing reduced foetal movements on seven or eight different occasions.
“But they looked at each incident as if they weren’t connected to one another. There was no continuity of care.
“She should have been re-graded from low risk to high risk, but she wasn’t, and we ended up having Kate at Ludlow Maternity Unit, 20 miles south of the Royal Shrewsbury.”
Richard, 49, an experienced photographer formerly covering areas of mid Wales – including work for Wales on Sunday – said Kate was placed in a cot while Rhiannon, originally from Llanddew, near Brecon, had a bath and recovered from the traumatic birth.
But 30 minutes after a midwife saw the baby was unresponsive and could not resuscitate her, she dialled 999 for an air ambulance to take her to a hospital better suited to her urgent medical needs.
The only briefing medical crew on the helicopter were offered was a small piece of card by the midwife, who did not go with her.
“Kate was meant to be airlifted to Royal Shrewsbury, but the helipad was closed,” Richard added.
“We were in a panic and had no idea where she was heading. We had to make our own way there, but Rhiannon collapsed and we had to take her to the Royal Worcestershire Hospital.
“Eventually we found out Kate had been taken to Birmingham Heartlands Hospital and was gravely ill.
“She passed away in my arms, while Rhiannon, who was bluelighted to our hospital, wasn’t able to arrive in time.”
Despite the scathing performance of maternity staff unearthed in the 2012 inquest, Richard said Shrewsbury and Telford Hospital NHS Trust rejected its findings.
It was only when the Parliamentary Ombudsman was brought in to investigate, in January 2015, that the trust was finally forced to admit its failings. A review of the trust’s own investigation found it was flawed and criticised midwives for retrospectively changing records and not following guidelines.
Then in 2017, following Richard and Rhiannon’s staunch campaigning alongside similarly grief-stricken parents Kayleigh and Colin Griffiths, an independent inquiry into the trust’s maternity services was launched by Health Secretary Jeremy Hunt and led by maternity expert
Donna Ockenden.
For the first time, after more than a decade of fighting, the catastrophic medical mistakes made not just in Kate’s care, but many hundreds of other cases, were finally being revealed.
Described as what is likely to be the NHS’s worst ever maternity scandal, a new leaked report has revealed a “toxic culture” stretching back 40 years where babies and mothers suffered “avoidable death”.
Children were also left with permanent disability amid sub-standard care.
“The study warns that, even to the present day, lessons are not being learned,” said Richard, who has now moved to Herefordshire and has a seven-year-old daughter, Isabella.
“We want this to be Kate’s legacy. We didn’t do it for any other reason than we want this trust to be accountable for this great tragedy which has affected so many other people.”
The inquiry’s initial scope was to examine 23 cases, but this has now grown to more than 600, covering the period 1979 to the present day.
The cases include 22 stillbirths, three deaths during pregnancy, 17 deaths of babies after birth, three deaths of mothers, 47 cases of substandard care and 51 cases of cerebral palsy or brain damage.
In the report, Mrs Ockenden wrote: “No apology will be sufficient or adequate for families who lost loved ones to avoidable deaths, or whose experience of becoming a parent was blighted by poor care and avoidable harm.
“Many families have described to me how they live on a daily basis with the results of that poor care.”
Paula Clark, interim chief executive at Shrewsbury and Telford Hospital NHS Trust, said: “On behalf of the trust, I apologise unreservedly to the families who have been affected.
“I would like to reassure all families using our maternity services that we have not been waiting for Donna Ockenden’s final report before working to improve our services.
“A lot has already been done to address the issues raised by previous cases.
“Our focus is to make our maternity service the safest it can be. We still have further to go but are seeing some positive outcomes from the work we have done to date.”