Bereaved mum’s battle to uncover truth behind baby deaths
RHIANNON Davies had no idea that her battle to find out why her baby daughter died just hours after birth more than a decade ago would uncover the biggest maternity scandal in NHS history.
What began as a campaign against cut-price maternity care transformed into a crusade against catastrophic failings and cover-ups at a hospital trust that newspapers including the Sunday Express helped to expose.
And it turned a heartbroken young woman into an activist, with the love and support of husband Richard and others.
Last week an independent inquiry into maternity services at Shrewsbury and Telford NHS Trust found that more than 200 babies and nine mothers may have survived had they received proper care. West Mercia Police are now investigating.
“I’m relieved,” said Rhiannon. “It was a battle to get this report across the line. Even after everything all these people have been through they were still trying to close it down at the 11th hour.”
Rhiannon’s relief is a million miles away from the despair that consumed her back in 2009.
In the weeks before giving birth to her daughter Kate at a midwifeled maternity unit in Ludlow, Shropshire, she had complained that the baby was not moving as much as earlier in the pregnancy.
The first-time mother in her early 30s had been admitted to hospital feeling unwell but midwives did not carry out any risk assessment. Instead they insisted a natural birth was best for both baby and mother.
After an exhausting 31-hour labour Kate was born at 10am on March 1, 2009, weighing 7lb 14oz.
She was cold, floppy and anaemic.
A midwife put her in an unheated cot in a side room and only called an ambulance when an assistant found the child in cardiac arrest.
She was transferred by air ambulance to a hospital in Birmingham.
The tiny infant was barely six hours old when she died in her heartbroken father’s arms.
Rhiannon admitted she “had not made a fuss”. To this day she finds it hard to forgive herself. “After she
was born I wanted to scream, ‘my baby’s dying! Please do something’, but I went along with everything they told me. I live with that regret,” she said.
At first the couple accepted their daughter was not “meant to live” but gradually it became clear those they trusted had betrayed them.
They felt the blame lay with the Government’s push for cheaper-torun midwife-led maternity units, and after consulting lawyers they asked for an inquest. Three times the coroner refused.
When the couple threatened a judicial review, he relented.
An inquest was heard by a new coroner in 2012 with just the Sunday Express and the local BBC station in attendance.
At the hearing the midwife admitted she had left Kate in a cold cot for a prolonged period because she was on duty alone. The nearest consultant was 30 miles away. “The NHS came with the sole object of
damage limitation,” said Richard.
Despite the verdict that Kate’s death should not have happened, no one apologised to the bereaved couple and no one was disciplined.
At the time the Shrewsbury and Telford NHS Trust described it as “a rare and tragic case”.
Kate continued to seek the truth but often felt as if she was “hitting her head against a brick wall”. After the birth of the couple’s second daughter Isabella, she came close to giving up in 2014, saying she couldn’t keep putting herself through the pain.
But in January 2015 the Parliamentary Ombudsman was brought in to investigate and the health trust was finally forced to admit a catalogue of failings.
A review of its own investigation found it was flawed, and criticised midwives for retrospectively changing records and not following guidelines.as the dossier of failings grew they applied pressure to then Health Secretary Jeremy Hunt, who eventually launched an independent inquiry led by senior
midwife Donna Ockenden. Initially the inquiry looked at 23 cases.
But it was expanded to investigate almost 1,600 after concerned families came forward.
The review found 300 babies died or were left brain damaged due to poor care.tragically, 201 babies and nine mothers could have survived had the Trust provided better care.
There were also 29 cases where babies suffered severe brain injuries and 65 incidents of cerebral palsy.
Ms Ockenden said the maternity services had “failed both families across Shropshire, and sometimes their own staff, over a prolonged period of time”. Only two midwives have been disciplined.
Marketing chief Rhiannon and photographer Richard, who live in Herefordshire, hope the report can transform maternity care.
“This report can make a difference – it should,” said Rhiannon. “I’m hopeful but I just don’t trust these people to do the right thing. Their only concern has been limiting reputational damage.”
But she added: “Without good solid journalism, without the scrutiny of media like the Sunday Express, God only knows if the truth would ever have come out.”
‘I don’t trust them to do the right thing’