Exclusive: Baby's death case with 'echoes of Morecambe Bay' to be re-examined

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.

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.

NHS England declined to comment.