'We've done it for Kate': Relief as seven-year fight over newborn baby death finally over
Ludlow couple Richard Stanton and Rhiannon Davies have spoken of their "vindication" today after fighting a seven-year battle with health chiefs over an investigation into their daughter's tragic death.
It has ended with the publication of an independent review into maternity services at the Shrewsbury and Telford Hospital NHS Trust which criticises health bosses for failing to properly investigate the death of their baby daughter Kate.
She died just six hours after being born at the midwife-led unit at Ludlow Hospital, despite being transferred to Birmingham's Heartlands Hospital.
Speaking after the report was made public yesterday, Rhiannon said: "From our point of view we are glad that everything is now out there because we feel we have done everything we can for Kate.
"We have fought to get the truth and to get the hospital trust to accept that truth – we've done that now, we've done it for Kate.
"It's all we could ever do for her and we had to do it.
"Any parent who found themselves in our position would surely do the same.
Simon Wright, chief executive of the Shrewsbury and Telford Hospital NHS Trust, today insisted "significant steps" had been taken. dThey include:
Substantial training for midwifery staff to ensure comprehensive knowledge
Additional education with four-yearly national neonatal resuscitation training and annual statutory updates to enable them to react appropriately if a baby suddenly deteriorates
Offering more opportunities for early intervention and ensuring more open discussion with patients or their families about how they want their concerns to be addressed
Recognising that the trusts previous approach when responding to complaints was too defensive and ensuring that its letters and other feedback are focused more on learning and improvement
Strengthening the trusts complaints team, including an experienced new head of complaints
Making sure that the trust board has regular discussions on the complaints it receives and how they are being handled
"What happens now? Of course we hope change will come from it.
"Change has to come from a tragedy – there is no greater strength than actually learning from a tragic event, putting the lessons learned into practice and ensuring that no other family, no other child and no other baby has to go through what we went through.
"That's what we've been striving for for years. We just hope Shrewsbury and Telford Hospital NHS Trust is a changed organisation and will now make the remaining changes."
It has not been an easy road for the couple. Richard said hospital bosses initially took their continued questioning as "an attack on them personally".
"Much was written about staff needing support," he said.
"No one ever thought to offer us support when all we were doing was seeking answers about how and why Kate came to die.
"The overarching opinion at the trust was that everything was fine, everything was done right, there was nothing to see – they reached this position based on no evidence at all because they never investigated Kate's death.
"The questions we put to them over the years were just deflected and met with half answers and untruths as this new report highlights. For us this report is vindication – but it's vindication tinged with great sadness for us because it has taken so long to get here and cost us so much.
"It wasn't until NHS England became involved that they agreed to do this review.
"If you run all of your Midwife Led Units (MLUs) without an operational policy – as they were until December last year – then they are just not safe.
"We've been highlighting such issues for years but they never wanted to hear us.
"These are issues that we were trying to raise with them, time and time again, with two different chief executives, Peter Herring and Tom Taylor. Every opportunity we presented to them to investigate. They weren't interested."
Unreserved apology
Shrewsbury and Telford Hospital NHS Trust chief executive Simon Wright has apologised "unreservedly" to the couple following the publication of the report and promised lessons will be learnt.
He said: "We believe that what we have been presented with is a fair and balanced report. The nature of the report's contents requires us, and other organisations, to ensure we are listening to families without them having to go to such lengths in order for their voices to be heard.
"The report describes how this trust failed to fulfil its responsibility to establish the facts of the case and to establish accountability.
"Rather, it abdicated that responsibility.
"This trust also did not put Kate's parents at the heart of the way it responded to their complaint, it did not address the issues they raised and its responses contained factual inaccuracies.
"This inadequate response placed an even greater burden on Rhiannon and Richard, who ensured that external reviews took place to tackle the deficiencies of our own investigations.
"The trust will be using this report to see if it raises any questions about the responsibilities of any individuals involved.
"We fully accept the recommendations in the report. We will hold a transparent process to ensure that they are seen through to their full conclusion, and updates on our progress will be reported to our trust board meetings, which are held in public.
"This trust offers a safe service for mothers, babies and families but there is clearly more that we must do to ensure that the learning from Kate's care is put into practice. It is important for all mothers and their families to know their child will be safe in our care. We want to provide every level of assurance we can.
"Nothing can make up for the loss of Kate but I sincerely hope that the improvements we have made and continue to make and the lessons we have learned and continue to learn will ensure that these tragic events are not repeated, but instead go to inform and shape our maternity care both now and in the future."
