Shrewsbury and Telford baby deaths 'victim blaming'

A MOTHER who lost her baby daughter in 2009 believes the Shrewsbury and Telford Hospital NHS Trust (SaTH) used "victim-blaming" as a way of distracting attention away from staff failings.

Rhiannon Davies, whose daughter Kate Stanton-Davies died after delays in transferring her from a community hospital to a doctor-led maternity unit, said she had felt physically sick while reading about the repeated lack of care and compassion found by the Ockenden report.

Speaking from her home in Herefordshire, she said: "I skimmed the themes initially and I was very impressed that the review team has got right to the heart of the matter.

"I felt very emotional… felt physically sick reading some of the family stories, the level of harm that babies and mothers have been subjected to – the lack of care, the lack of compassion, over and over again.

"It's very, very difficult reading."

The report acknowledged the efforts of Rhiannon and her husband Richard Stanton, and those of Kayleigh and Colin Griffiths, whose daughter Pippa died in 2016, for their "unrelenting commitment" to preventing similar deaths.

The review said maternity staff had caused distress to patients by using “inappropriate language” and blaming grieving mothers for their loss.

The inquiry into deaths and allegations of poor care at Shrewsbury and Telford Hospital NHS Trust (SaTH), set up in 2017, identified seven “immediate and essential actions” needed to improve maternity services in England.

Former senior midwife Donna Ockenden’s report said “one of the most disappointing and deeply worrying themes” was the “reported lack of kindness and compassion from some members of the maternity team at the trust”.

The chief executive of the trust apologised for the “pain and distress” caused to mothers and families due to poor maternity care – after the review found staff had been “flippant”, “abrupt” and “dismissive”.

Rhiannon Davies with her daughter in 2009. Picture: Richard Stanton

The review also said the deaths of Kate Stanton Davies in 2009 and Pippa Griffiths in 2016, whose families had campaigned for an independent review into maternity care at the trust, “were avoidable”.

Speaking about the report, Rhiannon Davies told the PA news agency: "Obviously these are critical recommendations. When Donna (Ockenden) launched the review this morning, she mentioned that she is working with a team of over 50 professionals.

"Clearly these professionals know what needs to happen, what needs to change and I feel confident that they've made strong recommendations for immediate change that will have a positive impact on the wellbeing of future mothers-to-be and their babies.

"I am impressed with the findings – my only concern is we've had reviews, we've had reports in the past – not just at SaTH, we've had Morecambe Bay.

"What will change? Who will scrutinise these recommendations? Who will ensure they are embedded not just at this failing hospital trust in Shrewsbury and Telford, but across the UK?

"That has to come from the Secretary of State for Health – that has to come from the top down."

Explaining how she and others had campaigned to protect other families in the future, the communications professional said: "Kayleigh and I worked very closely together following the deaths of our daughters, Kate and Pippa.

"We identified through talking to each other that there were such common themes between what had happened to cause the avoidable deaths of our babies.

"We spent some time going through death records, inquest records and we identified 23 cases which we put to Jeremy Hunt to ask him to instigate an independent review, which of course he did.

"The point was we knew we were not the only families and when the number grew to 60, the hospital trust put out a public statement saying that that was scaremongering.

"We are now at 1,862 incredibly brave families that have chosen to come forward and speak to the review.

"Yes, we did the initial ground work and it was hard, very hard. But it's testimony to all these other families who have come forward and whose own cases will enable positive change."

Describing the conduct of some staff towards grieving families identified by the report, Rhiannon added: "Victim-blaming, mother-blaming, I think, is a very convenient approach for this hospital trust – they would find any reason to cast doubt on what may have happened.

"In my own case I wanted to lie down and die to be quite frank with you – and they blamed me.

"Clearly this has happened to other families and other mothers and it's obviously a method that they used – because it would close you down, it would make you question yourself, not them.

"I am sure in many, many cases, that's what happened. Families were so crushed.

"The effect on me initially was hugely devastating.

"Fortunately, the post-mortem came out and we had the inquest and it was absolutely clear that Kate died as a result of a catalogue of catastrophic failings by the healthcare professionals who handled her."

She said of the staff behaviour identified by the report: "To do that to a family is disgusting – a core theme in this report is the lack of compassion, the lack of care.

"There are obstetricians calling mothers lazy, women lying there screaming in agony for hours because they need an intervention and people doing nothing.

"This is the 21st century. This is not Victorian England. How did this happen? How, why did no one speak out at the hospital trust?"