The avoidable death of a baby girl six years ago is to be re-examined after an independent national review warned the case had parallels with the Morecambe Bay care scandal.
- NHS England review finds original supervisory investigation ‘not fit for purpose’
- Hospital trust agrees to carry out new investigation
- Concerns raised about midwifery supervision system
- Parents blame “cultural problem” in midwifery
Baby Kate Stanton-Davies died in March 2009 after a catalogue of failures at a midwife led unit run by Shrewsbury and Telford Hospitals Trust, where she was born “hypothermic, pale, floppy and grunting”.
NHS England commissioned an independent review earlier this year after receiving a complaint in February from Kate’s parents, Rhiannon Davies and Richard Stanton. The report heavily criticised a previous investigation.
The parents told HSJ their lives had been “shattered” by their experience of battling the NHS for action over the case. The couple said they thought there was a problem in midwifery in the UK linked to the pursuit of natural births, with less medical involvement, which they believe contributed to the death of their daughter.
The report for NHS England was given to the trust last week and has been seen by HSJ. It concludes the investigation in 2009 by the local supervisor of midwives, Angela Hughes, who still works at the Shrewsbury trust, was “poor” and included “multiple inaccuracies”. The review also raises concerns about the national system of supervision for midwives, recommending a series of national audits and checks be carried out to ensure similar “weaknesses… are no longer inherent in the current process”.
NHS England review author Debbie Graham, a midwife and independent midwifery expert, said key events and lines of enquiry were not properly investigated by Ms Hughes. She said the trust’s “inappropriate reliance” on the flawed report meant it had delayed accepting failures had occurred and could not now be assured lessons had been learnt.
HSJ understands the trust has suspended a number of staff following receipt of the external review last week.
The review also suggested Ms Hughes had breached her own professional code of conduct by using “offensive” language at one point in her report to describe baby Kate as “it”.
The case comes amid mounting scrutiny of maternity services nationally. An ongoing NHS England-led review has been criticised for ignoring patient voices, and Morecambe Bay inquiry chair Bill Kirkup has warned that failings at that trust will be repeated if lessons aren’t learned.
In its conclusions the review for NHS England said: “It is the reviewer’s opinion that the facts in this case have not been established. It is of note that the reviewer identified significant factors in the case common with those identified in the Morecambe Bay investigation including poor quality records, retrospective completion of clinical notes and conflicting accounts of events.
“The finding of this review is that the supervisory investigation into the case of Kate Stanton-Davies and her mother Rhiannon Davies is not fit for purpose.”
The review recommended NHS England formally mark the trust’s original investigation as invalid and that a new investigation be carried out. The trust agreed last week, on receiving the report, to reinvestigate the case and its complaint handling.
‘Missed opportunities’ in Kate Stanton-Davies’ care
Kate Stanton-Davies was born at Ludlow midwifery led unit in Shropshire, in March 2009. The review by Debbie Graham for NHS England said midwives repeatedly failed to follow guidelines and best practice and she described an unexplained gap of half an hour between midwives finding Kate collapsed and a 999 call being logged by West Midlands Ambulance Service.
As an air ambulance transferred the baby to hospital her parents, who had to travel separatel, made frantic telephone calls to find out where there daughter had been taken. Rhiannon Davies then collapsed and was taken to Worcester Hospital while her husband was called to Birmingham Heartlands Hospital where Kate died at 4pm. Her mother arrived an hour later.
Before giving birth Ms Davies was admitted to hospital twice because of concerns over the baby’s health and had eight separate tests called a cardiotocography to monitor the baby’s heart rate.
Despite being seen by multiple midwives and reviewed by three consultant obstetricians, local and national guidance was not followed and she was wrongly classed as low-risk. Ms Davies was never offered a choice over her place of birth. The external review said these were multiple “missed opportunities” to ensure she was properly risk-assessed.
A jury inquest in 2012 and an investigation by the Parliamentary Health Service Ombudsman in 2013 both concluded Kate’s death was avoidable and the result of serious failings in care.
The trust, which had previously rejected two formal complaints by the parents, finally apologised and accepted serious systemic failings in January this year. After this result, the parents asked NHS England for a review of the trust’s initial investigation.
Ms Davies told HSJ: “The pain I live with as a result of this process causes me huge anguish on a daily basis. It has taken us six years to get the truth, now we want action, we want learning and we want accountability.
“When we saw the original investigation we were horrified and disgusted. The trust [initially] refused to give us a copy of the investigation and hid behind that document as a reason not to take any action.”
She said she believed she was denied a choice of location for her labour because of “an agenda of natural birth”. She added: “I believe there is a cultural problem at the core of midwifery. You have to have informed choice as a mother and I had no idea there was a co-located midwifery led unit at Shrewsbury Hospital. I didn’t know that I had that choice.
“The supervisory system for midwives can’t be seen as independent. You can’t have any level of objectivity or trust in something when you have midwives employed at the same trust as the midwives they are investigating.”
The Nursing and Midwifery Council, which is currently investigating midwives in relation to the case, accepted earlier this year that the local midwifery supervisory system needed to be changed, following failings at Morecambe Bay and Princess Elizabeth Hospital in Guernsey. However, this is likely to take a substantial amount of time and may require legislation.
‘We fell short’
Shrewsbury and Telford trust director of nursing and quality Sarah Bloomfield said in a statement to HSJ: “We recognise that the care provided for Ms Davies and her daughter in 2009 failed to meet the high standards we set for every one of our patients.
“Furthermore, we recognise that we also fell short in the trust’s complaint handling process, and we are truly sorry for the added pain and distress this has caused.
“As director of nursing and quality my first and foremost priority is the care and safety of our patients, which is why we have commissioned our own independent review into both the care and treatment provided to Ms Davies and her daughter and the trust’s subsequent handling of the couple’s concerns and the governance around the management of the incident itself.
“I have personally discussed this review with Mr Stanton and Ms Davies and they have kindly agreed to work with us to help ensure it examines all of their concerns.”
NHS England declined to comment.