It was the dedication of parents Rhiannon Davies and Richard Stanton, whose daughter Kate died in 2009, and Kayleigh and Colin Griffiths, whose daughter Pippa died in 2016, that meant the inquiry into maternity services at Shrewsbury & Telford Hospital NHS Trust, was even launched.
After being devastated at their own experiences and concerned about reports of other cases they wrote to the then Health Secretary Jeremy Hunt who ordered the inquiry.
Both families suffered tragic losses, with the hospital trust eventually accepting its failings in both cases.
Kate was born “pale and floppy” at Ludlow Community Hospital and died after delays in transferring her from Ludlow to a doctor-led maternity unit.
Ms Davies and Mr Stanton had to fight for years for answers, and the midwife involved was only struck off for a series of failings in 2018 – nine years later.
Mr and Mrs Griffiths’ daughter Pippa died on April 27, 2016, from a group b strep infection – the most common cause of meningitis in newborns. She was only one day old. At an inquest SaTH admitted failings in the information provided to Mrs Griffiths, which could have prevented her newborn daughter’s death.
The trust also accepted that had questions been asked when Mrs Griffiths raised concerns to a midwife over the phone then Pippa would have been taken to hospital, in all likelihood leading to her receiving treatment and surviving.
Ms Davies said the details of the report had left her shocked. She said: “I felt physically sick. I had to literally get up and go outside to get some fresh air and then go back through it slowly.
“Every single time it says a baby died it is very upsetting. You know your own case inside out but to see the trauma that other families have been subjected to is physically sickening.”
Both families have said the recommendations must be put in place without delay – with oversight to make sure they happen. Ms Davies said: “We want proof that it has happened. We would be very naive to trust this hospital trust to do what it should, because it has not done it before.”
Mrs Griffiths said there was a sadness that it had taken the efforts from the families to push for action.
She said: “It should not fall on the families that have already gone through so much to do this.”
She added: “I was an NHS member of staff at the time and I do not know how they can close us down and go from being supremely caring when you are going through the pregnancy and then when something happens the barrier comes down and you are now the enemy.”
‘I begged for a C-section but was pushed into a natural birth’
The experience of mother Hayley Matthews, who lost her son Jack hours after he was born in 2015, was one of the original cases that sparked the review of maternity care.
The Ockenden review has grown from looking at 23 cases of alleged poor care at the Shrewsbury and Telford Hospital NHS Trust to now more than 1,800.
Hayley, from Stirchley, Telford, was admitted to the Princess Royal Hospital to give birth after a straightforward, normal pregnancy.
Jack was born on March 15, 2015, but only lived for 11 hours.
A post-mortem revealed that he had died from fluid on the lungs caused by a group B Strep infection, as well as being starved of oxygen to the brain.
Hayley says throughout her labour, she “begged” staff to give her a caesarian but was ignored, and instead pushed into trying to deliver naturally.
Jack’s shoulder got stuck on the way out, and he suffered hypoxia – a lack of oxygen. Rarely harmful to adults, group B Strep is the UK’s most common cause of severe infection in newborn babies, causing sepsis, pneumonia and meningitis.
'A living nightmare'
Since then, Hayley has called for all pregnant women to be routinely tested for group B Strep bacteria.
Speaking last year, she said: “It’s been a living nightmare since I lost Jack.
“I’d never even heard of group B Strep before.
“No one in the medical profession had told me about it and I owe it to Jack’s memory to fight for change.
“All pregnant women need to be informed about group B Strep and not left in the dark, like I was. It’s like there’s a wall of silence around group B Strep and when you’re given so much other advice as a pregnant woman it seems ridiculous that something that could kill your baby or leave it with a long-term health condition is not mentioned.”
Prior to the Ockenden report being published yesterday, she said she had been “very anxious and nervous”.
“I’m hoping that they have learnt lessons from many years ago,” she added.
“I have waited five years and so has my family for this day to come.”