Shropshire parents floored by findings of report into baby daughter's death

Kate was found collapsed after being born with anaemia at Ludlow Hospital in 2009, and died six hours later despite being transferred to Birmingham's Heartlands Hospital.

The death left her parents Richard Stanton and Rhiannon Davies heartbroken, and the couple have spent six years fighting for a fresh investigation.

Despite a previous investigation into Kate's death, a new probe was ordered by NHS England in September after the original one was deemed "not fit for purpose".

Now that investigation, by two supervisory midwives with no links to Shrewsbury and Telford Hospital NHS Trust, has revealed a range of "system issues" at Ludlow's midwife-led unit at the time, and that changes were even made to Kate's clinical observation notes after her death.

The midwife who made the changes said she had been told to do so by her supervisor Angela Hughes, who also carried out the original investigation into Kate's death in 2009. The new report says vital policy documents covering recommended staffing levels and capacity at the unit did not exist, other trust policies and guidelines were out of date and the standard of documentation was poor.

It says that having just one midwife on duty was described as normal, with nearby off duty midwives only called if needed, and it was "accepted practice" for midwives to rely on a verbal call to the hospital ward rather than have clinical records faxed to the midwifery led unit, despite this being against trust policy.

One midwife, who told the inquest into Kate's death her training was up to date, had not attended training since 2006, it was revealed. When Kate needed resuscitation she failed to do this properly and said she was "in a bit of a panic as this was the first time she had had to resuscitate a baby", the report says.

Kate's parents said the results showed systemic problems in healthcare in 2009 and urged others in similar cases to call for a reinvestigation if they felt they were not satisfied the first time around.

Rhiannon said: "We've long known about many of the mistakes and systemic failings at SaTH that contributed to Kate's avoidable death. But when we received this report we were floored by the new facts it brought to light, such as the fact that the original investigating midwife, whose report NHS England declared not fit for purpose, told those she was investigating to go back and change Kate's notes.

"It's difficult to imagine that almost seven years after Kate's death, when we have been committed to uncovering the truth about her death for so long, that still new evidence can be unearthed. It breaks my heart that they would attempt to keep facts from us – it's like they are refusing to give a part of my daughter back to me.

"You would think that losing Kate in such shocking and distressing circumstances would be the worst event in my life but the continual need to revisit the trauma of that day as we fight to get the truth means that my distress is ongoing.

"How can I begin to learn to live around the hole in my life when I am forced to relive Kate's painful and avoidable death every single day of my life? How many other baby deaths were avoidable, how many other investigations were not fit for purpose, how many other families have been betrayed, and how many other opportunities for learning have been lost?"

More deaths will be reviewed by health chiefs in Shropshire in the wake of the fresh investigation into baby Kate Stanton-Davies.

Officials at Shrewsbury and Telford Hospital NHS Trust (SaTH) have accepted the findings of the new investigation and that lessons have been learned.

Simon Wright, chief executive of SaTH, said the trust was a "very different organisation" to what it was in 2009, but added other deaths from that period would now be reviewed.

He said: "We recognise that the care provided for Rhiannon and her daughter in 2009 failed to meet the high standards we set for all of our patients and that the trust's complaint handling process fell short of what is expected.

"We have unreservedly apologised for these shortcomings, and do so again. The trust is taking appropriate action in accordance with trust policies and procedures, in respect of this matter.

"To reassure us, our patients and communities that there were no wider cultural problems in 2009, we are using our incident reporting system and reviewing any other deaths from that period to look into whether there are any themes or trends which may have been overlooked. One of our independent non-executive directors is also overseeing the care group to further strengthen this process.

"We truly do believe that we are a very different organisation than we were seven years ago.

"I'm reassured about the current culture through independent assessments of the service, feedback from patient listening groups, surveys of women who use our services and regular senior leadership walkabouts. But we're determined to keep on learning and I'm committed to working with Rhiannon and Richard to ensure lessons are learned."

Sarah Bloomfield, director of nursing and quality at SaTH, said there had been "significant improvements" in how maternity services are run.

She said there had been a comprehensive review of maternity services in 2013, and the inquest into Kate's death held in 2012 "provided important recommendations".

She said when she read that policies to do with mother and baby care were out of date, and that the midwife tasked with resuscitating Kate was not up to date with her training as she said at the inquest, she "felt absolutely devastated and bewildered."

She said the unit had no operational policy when Kate died and was still without one when Debbie Graham for NHS England investigated last year. "

We owe a massive debt of gratitude to NHS England for listening to us and committing to completing this report for Kate," she said.