Is an NHS obsession with natural childbirth behind the deaths of seven babies at one hospital trust?
EIGHT years have gone by since Rhiannon Davies’s baby daughter died, but the pain of her loss has not eased. What hurts most is the knowledge that she was not there when Kate, hours old, passed away.
‘My husband was there and held Kate in his arms while she died, but I wasn’t,’ says the 42-year-old. ‘It is something which haunts me every single day of my life.’ Instead, she is left with the memory of rushing to the hospital to be confronted by a stony-faced nurse. ‘I said: “She’s dead, isn’t she?” . . . and the nurse nodded. I just collapsed.’
Since that day in March 2009, Mrs Davies and her husband, Richard Stanton, have unearthed a litany of errors, and a cynical cover-up.
Only after a lengthy legal battle did Shrewsbury and Telford Hospital NHS Trust (SaTH) fully apologise — promising it was doing everything in its power to stop other parents suffering in the same way.
But last year, another parent who had also lost her baby while being cared for by SaTH’s midwives, came forward and this week, with Mrs Davies’s help, a BBC investigation revealed the horrifying extent of the problem.
It identified a cluster of seven baby deaths between 2014 and 2016 linked to SaTH, all avoidable. There were also other deaths outside that timeline.
As Jeremy Hunt, the Health Secretary, ordered an investigation, the Mail can reveal that a further nine families have come forward this week to say that they too had lost babies in questionable circumstances.
Five of the original seven deaths involved failures in monitoring the baby’s heart rate properly.
Some parents also claim that they felt under pressure to have a ‘ natural’ birth without anaesthetic, forceps, induction or Caesarean, in units that were supervised by midwives rather than by consultant obstetricians.
PARALLELS are being drawn with the Morecambe Bay maternity scandal, where failings by midwives who pursued natural childbirth at all costs led to the unnecessary deaths of one mother and 11 babies.
It is a point forcefully made by Mrs Davies, now the mother to Isabella, five, born following an elective Caesarean section. ‘ The midwives’ role has been hijacked by militant natural birth promoters. Babies are dying because of the agenda.’
every year the SaTH, which runs the Princess Royal Hospital in Telford and Royal Shrewsbury Hospital, oversees the delivery of some 4,700 babies. While the vast majority are incident-free, fatalities do occur.
like any first-time mother, Mrs Davies, from Hereford, put her health in the hands of the medics. Her pregnancy had been straightforward until the final month. Then, concerned about the baby’s reduced movement, she underwent a number of overnight stays at the Royal Shrewsbury Hospital.
Tests proved inconclusive and doctors assured her everything was fine. The birth duly went ahead at the midwife-led maternity unit at ludlow Hospital.
After a 31-hour labour, Kate was born weighing 7lb 14oz just after 10am on March 1, 2009. She was pronounced dead shortly after 4pm.
There were warning signs during the labour that all was not well. ‘There were three episodes of Kate’s heart-rate plummeting, but no action was taken,’ says Mrs Davies.
‘When she was born, she was noted to be pale and floppy, hypothermic, had no suck reflex and was grunting which meant she was in respiratory distress, yet the midwife took no action.
‘When I asked if everything was OK, I was told everything was fine and I should have a bath. I walked out of that room and never saw my baby alive again.’
After Kate was found in a state of collapse, paramedics requested an air ambulance to transfer her to a bigger hospital. The helicopter headed for Shrewsbury, but the hospital’s helipad was closed. Kate was eventually flown to Birmingham Heartlands Hospital.
left behind, her parents had no idea which hospital she had been sent to. The trauma left Mrs Davies so ill that she collapsed and another ambulance had to be summoned.
The paediatricians in Birmingham kept Kate alive long enough for her father to arrive. She died in his arms. Mrs Davies had been diverted to a hospital in Worcester and was not reunited with Kate until 90 minutes after her death. ‘It became clear that she was never really given a proper chance of survival,’ says Mrs Davies.
WHEN the coroner said there was no reason for an inquest, the couple threatened a judicial review. The hearing went ahead in 2012, finding that Kate could have survived had she been born at a hospital staffed by obstetricians rather than a centre with midwives only.
SaTH refused to accept the findings, so Kate’s parents pushed for an independent review. Commissioned by NHS england, it found an original probe by the local Supervising Authority, which cleared midwives of wrongdoing, was ‘not fit for purpose’.
last year, a second investigation found a ‘lack of a safety culture’ at SaTH in 2009, that it had not held any staff accountable for failures over Kate’s death, and lessons were not learned. Changes had been made to Kate’s observation notes after her death.
While SaTH finally issued an unreserved apology, in April 2016, another baby, Pippa Griffiths, died while under SaTH’s care.
Mrs Davies and Mr Stanton, a 47-year- old photographer, were contacted by Pippa’s parents, Kayleigh and Colin. They, too, were desperate to learn what happened to their child, not believing SaTH’s assurances that nothing could have been done to prevent her death. Again, they pushed for an inquest.
It duly found that the oneday- old baby’s death could have been prevented if her mother’s concerns had been acted upon.
Pippa died from a Group B Streptococcus infection
— the most common cause of meningitis in newborns. The inquest in Shrewsbury was told that Mrs Griffiths, who had given birth at home with two midwives, was not provided with a leaflet on potential warning signs.
Had questions been asked when Mrs Griffiths called a midwife to raise concerns about Pippa’s lack of feeding and bringing up brown mucus, she would have been taken to hospital. Mrs Davies and Mrs Griffiths decided to see if other babies had died in similar ways. Mrs Davies said: ‘ We looked through death and inquest records and uncovered many more incidents of babies who’d died or been avoidably harmed, and mothers who died as well.’
They passed their findings to the BBC as well as contacting Jeremy Hunt. He has asked NHS England and NHS Improvement to contact the families to ensure they had been properly investigated.
Similarities between cases are worrying. In 2014, Kelly Jones, a mother of two, discovered she was pregnant with twin girls.
During her pregnancy, she felt pain. But despite repeatedly asking staff at the Royal Shrewsbury Hospital to assess her properly, she was ignored.
By the time medics took her seriously, it was too late. Her twins, Ella and Lola, were stillborn that September. Kelly, from Shrewsbury, said: ‘The midwife came in crying, saying: “I’m so sorry, I’m so sorry.” My girls are gone because they couldn’t be bothered to do their job.’
A SaTH investigation found they died from oxygen starvation to the brain ‘contributed to by a delay in recognising deterioration in the foetal heart traces and missed opportunities for earlier delivery’.
In March 2015, Oliver Smale died after his shoulders became stuck during a natural birth at the Princess Royal Hospital in Telford. An inquest heard the death would have been avoided had a Caesarean been carried out as planned.
That August, Kye Hall died soon after his birth at the same hospital. A coroner recorded his death was ‘caused or contributed’ to by SaTH, which failed to classify his mother as a high-risk pregnancy or to listen to his heartbeat.
The inquest heard that SaTH accepted some heart rate recordings of the unborn baby had not been taken or recorded, and it was accepted that his mother, Katie Anson, could have been referred to the consultancy-led unit when her blood pressure dropped.
The same year, Graham Scott Holmes-Smith was stillborn. SaTH later acknowledged the baby would have been likely to have been born alive if his heart rate had been properly monitored.
Then in late 2015, Ivy Morris was born severely brain damaged, dying in May 2016. Midwives caring for her mother Tamsin, a nurse who works for SaTH, mistakenly monitored her heartbeat during labour instead of the baby’s.
There was also a delay in the second stage of labour. Added to that is the death of Pippa Griffiths in April 2016.
While many cases highlight failures in heart rate monitoring, they have also focused attention on concerns that women can be pressured into ‘natural’ births.
Adam Gornall, clinical director for maternity at SaTH, said he did not believe the Trust prioritised ‘ normal’ childbirth without medical intervention.
He said: ‘The Trust has MidwifeLed Units across the large rural county of Shropshire which work within closely monitored criteria to ensure those women choosing to deliver at the units are appropriate to do so.
‘ The criteria are decided in conjunction with the obstetric team and, more recently, have been discussed within the wider maternity network covering Staffordshire, Shropshire and the Black Country. Over the past few years there has been a steady decline in the number of women either eligible, or choosing, to deliver within the units, reflecting a trend that is supported by the midwifery staff.
‘In 2013/14, the Royal College of Obstetricians and Gynaecologists published Maternity Indicators comparing different units’ performance in relation to rates of different actions and outcomes. The document indicated SaTH has a lower than average Caesarean section rate.
‘Closer inspection of the data shows that for those women enter- ing labour, the chance of them having an emergency Caesarean section was within normal limits. This would suggest there is not a drive towards normal birth in this situation.’
James Titcombe, who fought for the investigation into the cover-up at Morecambe Bay after the death of his son, Joshua, in 2008, said he was deeply concerned.
‘The themes are always the same. Often parents’ concerns that “something isn’t right” are ignored, signs and observations that should have resulted in obstetric involvement aren’t acted upon, and instead, midwives push for a normal delivery resulting in catastrophic and entirely avoidable consequences.
‘We can either keep on dismissing these tragic events as unfortunate rare occurrences that can’t be avoided or we must finally recognise this is a systemic issue rooted in an ideology that prioritises achieving a “normal delivery” and the “experience” of birth, over safety.’
In a statement, Simon Wright, SaTH’s chief executive, apologised ‘unreservedly’ to the families.
H E SAID: ‘In recent years, independent external reviews have repeatedly shown the Trust is progressing and learning lessons but we must strive to do more.
‘All our staff want our care to be the safest and kindest it can be. Since I joined the Trust in late 2015, I’ve seen how our hospitals have been working hard to promote a culture of learning, not blame.
‘We are candid and open about any failing in order that we might spare the families further heartache, or the need for challenge to get to the truth.’
He added that midwives had special training in foetal heart monitoring and analysis, and investment had been made in new equipment.
‘The Care Quality Commission (CQC), Healthwatch and independent experts have all described our service as good,’ he said.
‘We have also invited the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives in to review our learning, and revisit us to provide further independent assurance of our progress and help us continue to improve.’
But Mrs Davies believes a public inquiry is the only way forward.
‘The hospital trust is still in denial,’ she said. ‘We’re not the only ones and now there is momentum behind us. We are not going away.’