Fury at NHS over death of Ludlow couple's newborn baby

The jury's verdict yesterday was that the baby's mother should never have been taken to the unit at Ludlow Community Hospital following complications.

Rhiannon Davies was taken to Ludlow, and about two hours after giving birth to Kate Seren Stanton-Davies the baby was airlifted to Birmingham Heartlands Hospital where she died.

Miss Davies and Richard Stanton, of Dahn Drive, Ludlow, fought for more than three-and-a-half years to discover exactly what happened and yesterday said they were satisfied with the verdict at the end of the inquest in Bridgnorth.

Miss Davies said: "Lessons must be learned and change implemented to ensure no other family has to endure what we have been through."

The couple described the care given to Kate as 'a complete and utter catastrophe' and claimed everything which could have gone wrong did.

Miss Davies reported reduced foetal movement in the two-and-a-half weeks before Kate was born at the midwifery-led maternity unit at Ludlow Community Hospital at 10.03am on March 1, 2009.

Kate suffered a collapse and was flown by the West Midlands Air Ambulance to Birmingham Heartlands Hospital where she died at 4.05pm the same day.

She died from brain damage caused by anaemia which was brought on by a rare pregnancy condition in which blood leaks from the foetus into the mother.

Neither Miss Davies nor her now husband Mr Stanton were flown with her or were even told where she had gone and how.

Mr Stanton eventually caught up with Kate just in time to hold her for the last five minutes of her life.

Miss Davies did not reach Heartlands until 90 minutes after she died.

Miss Davies, 38, and Mr Stanton said in a statement after an inquest yesterday ruled Kate might have survived had she been delivered elsewhere: "Throughout the various stages of my pregnancy and Kate's birth we, as a family, have been let down by the various organisations within the NHS.

"Knowing what we know now I would never have consented to have given birth at Ludlow maternity unit.

"We have grave concerns about the quality of midwifery care that Kate received after her birth."

Cathy Smith, head of midwifery and deputy centre chief for the women and children's centre at The Shrewsbury and Telford Hospital NHS Trust, said: "Kate's death was a rare and tragic case and once again we would like to offer our sympathies to Miss Davies, Mr Stanton and their family.

"We will now be taking the time to reflect on the jury's findings and the helpful comments made by the coroner throughout this complex and thorough inquest.

"Assessing the risks of pregnancy and delivery is complex and risks can never be removed completely."

Abmbulance service statement:

West Midlands Ambulance Service have issued a statement in the wake of the inquest into the death of baby Kate Seren Stanton-Davies defending the actions of its staff and the care provided for her.

Spokesman Murray MacGregor expressed the condolences of the service to Kate's family.

He added: "This must have been a particularly difficult two weeks for them but hopefully the inquest has enabled them to find out many of the answers that they had been seeking."

Mr MacGregor said that when paramedics attended for Kate in the delivery room at the midwifery-led unit Miss Davies was not present and the priority was to get Kate to hospital.

"The Inquest has shown that the care provided by the ambulance crew and the doctor and paramedic on the air ambulance was appropriate and they did everything they could to get Kate to Heartlands Hospital in Birmingham, a Level 3 neonatal unit, in the shortest possible time," he added.

"The air ambulance took only 15 minutes to get Kate to Heartlands Hospital.

"A road ambulance would have taken at least 40 minutes to get to Royal Shrewsbury and the landing site was, in any event, unavailable.

"Tragically, the evidence of the pathologist and expert neonatalist clearly showed that Kate could not have survived by the time that the ambulance was called even if the call for our assistance had been made earlier.

"The lack of notes handed over to doctors at Heartlands Hospital relating to Kate was considered at the inquest. As no clinical notes were in fact made by the midwives at Ludlow Midwifery Led Unit, there were no notes for the air ambulance doctor to provide."

Mr MacGregor said the ambulance service informed both Ludlow midwifery-led unit, when Kate's mother was still there, and the Royal Shrewsbury Hospital, that Kate had been taken to Heartlands Hospital.

"During the inquest the midwives at Ludlow said that they did inform the parents of this and indeed printed off a map of the route to Heartlands Hospital for them," he said.

"Unfortunately, it appears that Kate's parents did not take in that information."