Shropshire maternity probe: Tiny lives lost due to medical mistakes
It was the death of Kate Stanton-Davies, just six hours after she was born, that sparked concerns about maternity services in Shropshire.
Simon Wright, chief of Shrewsbury and Telford Hospital NHS Trust, apologised to mother Rhiannon Davies and husband Richard Stanton after an independent inquiry identified a catalogue of failings and shoddy record-keeping which contributed to her death.
Two midwives were held responsible for the errors, one of whom was unable to spot obvious signs Kate was seriously ill.
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 report said hospital bosses failed to properly investigate Kate’s death, failed to hold staff to account and failed to address concerns raised by Miss Davies and Mr Stanton. “The trust abdicated its responsibility,” the report said.
Miss Davies said: “What’s so difficult about what is coming out is that things have been and continue to be far worse than even we knew.
Compounding this pain is the fact I now know acres of learning from avoidable deaths existed before Kate.
“Unlike what I was led to believe in 2009, Kate was not the first avoidable death at the trust. Yet no-one bothered to learn, and so sealed her fate, and mine, and that causes me almost unbearable pain.”
Miss Davies, and fellow mother Kayleigh Griffiths wrote to then health secretary Jeremy Hunt in 2016, highlighting the 23 cases of poor care they were aware of, which led directly to Mr Hunt commissioning the independent Ockenden review.
Mrs Griffiths’ daughter Pippa died 31 hours after her birth in April 2016. An inquest found hospital staff missed crucial opportunities to save the baby on two occasions when her mother telephoned the hospital.
The inquest heard that a midwife was due to visit Mrs Griffiths on the afternoon after Pippa’s birth, but failed to show up.
Pippa developed a purple rash that night and stopped breathing.
In a third case, Jack Burn died 11 hours after being trapped in the birth canal.
His mother Hayley Matthews, from Chirbury, had been assured nothing was wrong with her pregnancy, but later learned that Jack had been distressed for 20 minutes before delivery. Jack also contracted group-B streptococcus, an lethal infection carried by one in five women.
He died in March 2015 at PRH, hours after another baby, Oliver Smale, died following similar complications.