Independent Review

This page will provide information about the independent maternity review published in April 2016.

An independent Maternity Review was published on 1 April 2016. It looks at the tragic death of Kate Stanton-Davies in 2009, hours after being born at Ludlow Midwife-Led Unit.

The report looks at both the care and treatment provided to Kate and her mother and the Trust’s subsequent handling of Kate’s parents’ concerns and the governance around the management of the incident itself.

The full report will be discussed at a special meeting of the Trust’s Board at the Shropshire Conference Centre at the Royal Shrewsbury Hospital at 3pm on Monday 4 April 2016.

The full report can be found here.

A newsletter looking in detail at the report and our learning can be found here.

Below is a statement from Simon Wright, Chief Executive of The Shrewsbury and Telford Hospital NHS Trust (SATH):

I would like to apologise unreservedly for the shortcomings in care provided by The Shrewsbury and Telford Hospital NHS Trust (SATH) that contributed to the death of Kate Stanton-Davies in 2009.

I would also like to apologise that the way this Trust handled the complaints raised by Kate’s parents, Rhiannon Davies and Richard Stanton, fell far short of the standards we all have a right to expect, and that this added significantly to the pain and distress they had already experienced.

Today’s report makes difficult reading – even more so because it has only come about because of the determination of Richard and Rhiannon to bring to light the failures of the original investigation, the quality of care we should have afforded them and our failings in protecting Kate when she was at her most vulnerable.

It is important that this independently commissioned report was carried out by somebody the family had confidence in. We believe that what we have been presented with is a fair and balanced report. The nature of the report’s contents requires us, and other organisations, to ensure we are listening to families without them having to go to such lengths in order for their voices to be heard.

We fully acknowledge the failings identified in this report and the harm they have caused to Richard and Rhiannon.

The report describes how this Trust failed to fulfil its responsibility to establish the facts of the case and to establish accountability. Rather, it abdicated that responsibility to the Local Supervisory Authority (LSA), which is independent of the Trust. In 2017, the rules around LSAs undertaking such investigations will change. This Trust also did not put Kate’s parents at the heart of the way it responded to their complaint, it did not address the issues they raised and its responses contained factual inaccuracies.

This inadequate response placed an even greater burden on Rhiannon and Richard, who ensured that external reviews took place to tackle the deficiencies of our own investigations. The Trust will be using this report to see if it raises any questions about the responsibilities of any individuals involved.

We fully accept the recommendations in the report. We will hold a transparent process to ensure that they are seen through to their full conclusion, and updates on our progress will be reported to our Trust Board meetings, which are held in public.

We have already taken significant steps including:

  • Substantial training for our midwifery staff including initial orientation combined with subsequent rotation to ensure comprehensive knowledge
  • Additional education with four-yearly national neonatal resuscitation training and annual statutory updates to enable them to react appropriately if a baby suddenly deteriorates
  • Offering more opportunities for early intervention and ensuring more open discussion with patients or their families about how they want their concerns to be addressed
  • Recognising that our previous approach when responding to complaints was too defensive and ensuring that our letters and other feedback are focused more on learning and improvement
  • Strengthening our complaints team including an experienced new Head of Complaints
  • Making sure that the Trust Board has regular discussions on the complaints we receive and how they are being handled

At our Midwife Led Units, our Midwives undergo training in various scenarios which may occur during childbirth to ensure their skills and techniques are up-to-date. We also hold “skills drills” at our Consultant Led Unit. These ensure that our Midwives are able to manage any emergency situation, however rare.

A Focus group has taken place involving staff from our Midwife Led Units and the Consultant Led Unit, which focused on ensuring they were aligned and compliant with policy. Focus groups also looked at workforce development, staff rotation and safety as well as highlighting what we offer to attract new staff and keep existing staff. These led to some positive developments. We have carried out a review of 10 cases about transferring patients from MLUs and found that in all 10 cases, staff had followed policy and had safe transfers.

The aim of focus groups is to find ways we could improve the service through education and service improvements. We’ve also looked at other ways we can improve. Overall the work showed that we have a safe service, but need to ensure that we are constantly looking at ways to improve and ensuring we are in line with national guidance.

When serious incidents do occur, we adhere to expectations under the Duty of Candour Regulations, to ensure we are open and transparent with patients and their families about how we will put things right where safety has been compromised.

Having recently joined the Trust, I am reassured that the report finds that learning from these tragic events has led to considerable improvements in Maternity Service Clinical Governance and the Trust’s complaints processes.

This Trust offers a safe service for mothers, babies and families but there is clearly more that we must do to ensure that the learning from Kate’s care is put into practice. It is important for all mothers and their families who are placing their trust in us to know their child will be safe in our care. We want to provide every level of assurance we can to any mothers coming to us.

Nothing can make up for the loss of Kate but I sincerely hope that the improvements we have made and continue to make and the lessons we have learned and continue to learn will ensure that these tragic events are not repeated, but instead go to inform and shape our maternity care both now and in the future.