Tragic: Richard Stanton and Rhiannon Davies lost their daughter Kate after failings by NHS staff which led to the baby being born in a midwifery unit rather than a hospital
The death of a newborn baby could have been avoided if the child had been born in a hospital rather than a midwives unit, an inquest has ruled. A couple slammed the NHS after losing their tiny daughter just six hours after she was born, claiming she should have had better treatment. Kate Seren Stanton-Davies died on March 1, 2009, after suffering from a rare pregnancy condition in which blood leaks from the foetus into the mother.
Her mother Rhiannon Davies, 38, a technical writer from Ludlow, Shrops, suffered complications in the last month of her pregnancy, which lead to a series of hospital trips and tests. Just two hours after being born at Ludlow Community Hospital, tiny Kate suffered a collapse and was flown by the West Midlands Air Ambulance to Birmingham Heartlands Hospital where she died at 4.05pm the same day. On Friday (Nov. 16), an inquest jury at South Shropshire Coroners' Court unanimously concluded that the baby would have survived if she had been delivered elsewhere, and the decision by clinicians to treat Mrs Davies' pregnancy as low risk contributed to Kate's death.
Mrs Davies and her husband Mr Stanton, who got married in December last year, described the care given to Kate as 'a complete and utter catastrophe', and say everything which could have gone wrong did. Speaking after the inquest, Mrs Davies said: 'Lessons must be learned and change implemented to ensure no other family has to endure what we have been through. 'Throughout my pregnancy and Kate's birth we, as a family, have been let down by the various organisations within the NHS.
Anger: Ludlow Community Hospital where Rhiannon Davies gave birth to her daughter Kate
'Knowing what we know now I would never have consented to have given birth at Ludlow maternity unit. We have grave concerns about the quality of midwifery care that Kate received after her birth. Following the inquest we now know that she was left alone in a cold cot in a hypothermic state with signs of respiratory distress by a midwife who was meant to be caring for her. That image haunts us.' Mr Stanton, a professional photographer, told The Sunday Times: 'The hospital trust were, and are responsible for the death of our daughter. The questions we have been battling to get answered for three years and eight months have finally been answered by a unanimous jury verdict.'
A happier time: Rhiannon Davies, of Ludlow, Shropshire, pictured in her 36th week of pregnancy, just five weeks prior to the birth of her baby Kate Seren who died after a collapse
After the inquest, Cathy Smith, head of midwifery and deputy centre chief for the women and children's centre at The Shrewsbury and Telford Hospital NHS Trust, said: 'We will now be taking the time to reflect on the jury's findings.' Ian Cohen, of Goodmans Law, the family's solicitor, told the newspaper: 'Lessons must be learnt, but it is of critical importance that mothers-to-be are fully informed and give full and informed consent.' The inquest also heard of a catalogue of transportation failings in rushing the couple to be with their dying daughter. West Midlands Ambulance Service refused to treat Kate's mother as a priority, and told her she may have to wait up to four hours to be transported to be with her dying daughter.
Not wanting to be separated, Mrs Davies and her husband Richard Stanton, 42, decided to drive themselves to Birmingham to find Kate and attempted to follow the helicopter by car. But during the journey, the new mother collapsed from an acute stress reaction, and an emergency ambulance had to be called which, instead of taking her to Birmingham, transferred her to Worcester Hospital instead. Photographer Mr Stanton eventually found out where Kate was being treated having rung around multiple hospitals in the West Midlands desperately trying to find her. He arrived just in time to hold her for the last five minutes of her life, but Mrs Davies did not reach her until 90 minutes after she died.
Dr Andrew Carson, medical director for the West Midlands Ambulance Service, commented in a report to the family: 'Logistical and procedural issues within WMAS led to an unsatisfactory experience for this family at a time of great difficulty for them.' In response to this statement Mr Stanton said: 'If one flies with a budget airline one might have an unsatisfactory experience. But the fact that it took 58 minutes from the 999 call being made to Kate arriving at Heartlands Hospital, where she died in my arms, makes this comment grossly inappropriate.' A spokesperson for West Midlands Ambulance Service later claimed they did everything they could to save baby Kate.
Intimate: Rhiannon Davies just moments after the birth of her baby daughter on March 1 at Ludlow Community Hospital. Tiny Kate died on the same day after she was airlifted to hospital.
Spokesman Murray MacGregor said: 'The inquest has shown that the care provided by the ambulance crew and the doctor and paramedic on the air ambulance was appropriate and they did everything they could to get Kate to Heartlands Hospital in Birmingham, a Level 3 neonatal unit, in the shortest possible time.' But yesterday, Mr Stanton said he was disgusted with the response the grieving family received from the West Midlands Ambulance Service. He said: 'The ambulance service said the flight time for the air ambulance to get Kate to Heartlands was just 15 minutes. But the inquest heard the actual time from departure to arrival was 58 minutes. It's clear to us that by their response they are still in denial that their actions contributed to the suffering of our daughter. Ultimately... my daughter would only be alive today if the clinicians from the Shrewsbury and Telford Hospital Trust had listened to mine and my wife's concerns about our baby, both before she was delivered and immediately following her birth.'
Source: Daily Mail UK