Rhiannon Davies

In March 2009 Rhiannon Davies gave birth to a daughter, Kate Stanton-Davies, at a midwife-led maternity unit in Ludlow. In the two weeks before the birth Davies had complained that the baby was not moving as much as previously, and had herself been hospitalized after feeling unwell. However, midwives had not carried out any risk assessment or adjusted her birth plan. Kate was born cold and floppy, with hyperthermia and anaemia. A midwife placed Kate in an unheated cot in a side room, and only called an ambulance when a health care assistant found Kate in cardiac arrest.

Kate died after being transferred to a Birmingham hospital.[1] Though Kate was cremated, the Emstrey crematorium did not use settings appropriate for infants. So Rhiannon and her husband Richard Stanton were told there were no ashes.[2]

Rhiannon Davies and her husband Richard Stanton made formal complaints to the trust, the West Midlands Ambulance Service and the Nursing and Midwifery Council. Initially refused an inquest, they managed to secure one in 2012. The inquest jury unanimously found that Kate's delivery at a midwife-led unit contributed to her avoidable death.[1] They then secured the Health Service Ombudsman's attention to the case after Shrewsbury and Telford Hospital NHS Trust refused to accept the findings of the inquest. The Ombudsman upheld the family's complaint, concluding that Kate's death had been avoidable, and that the Trust was responsible for both service failure in Kate's care and maladministration in handling the complaint.[1] In 2015, after a Shropshire Council inquiry reported into Emstrey crematorium's treatment of infant remains, the council also issued an apology to Davies and the parents of over fifty infants. Davies criticised the report for ignoring concerns which crematorium staff had raised, and for misrepresenting the problem as an historic problem.[2]

After the original NHS England investigation into Kate's death was found "not fit for purpose", a second one reported in February 2016. The report found a range of "system issues", with changes even made to Kate's clinical observation notes after her death.[3] Later that year, an independent review concluded that the trust had not met its responsibility to establish the facts about why Kate's death had occurred. It concluded that the trust was "indebted" to the tenacity of Ms Davies and Mr Stanton, and needed to work in partnership with them "to establish a fitting acknowledgement of the contribution they have made to the safety and quality of maternity services at SaTH".[4]

In 2017 Davies, Stanton and two other bereaved parents asked the UK health secretary, Jeremy Hunt, to set up a public inquiry into maternity services at Shrewsbury and Telford Hospital HNS Trust.[5] Though Hunt did not establish a public inquiry, he ordered an investigation in April 2017.[6]

As the review uncovered wider evidence of maternity services failings at the trust,[7] with over 60 cases needing investigation,[8] Davies called on Hunt's successor, Matt Hancock, to widen the review's remit.[9] By Jun 2019 hundreds of cases were under investigation.[10] In November 2019 the leaked interim report confirmed Davies' worst fears and vindicated her efforts:

I couldn’t accept that we were the only people that this had happened to which is why we pushed for an investigation. But I am devastated that so many people have been treated in such a way and other families have suffered. How has this been tolerated for so long? It is horrific [...] It takes a massive toll to keep fighting. We have done it for Kate. There is a cultural problem nationally in maternity. We need to have a more grown-up conversation about the risks of pregnancy. No one ever wants to think about death in maternity.[11]

When published in December 2020, the first Ockenden Report singled out the difference made by Davies, Stanton and two other bereaved parents, Kayleigh and Colin Griffiths:

The parent’s unrelenting commitment to ensuring their daughters’ lives were not lost in vain continues to be remarkable [...] In a void described by the families as ‘incomprehensible pain’, they undertook their own investigations to highlight the deaths of their newborn daughters, and to insist upon meaningful change in maternity services that could save other lives.[12]

In the House of Commons, Jeremy Hunt also paid tribute to the achievement of the grieving families, for overcoming a 'blame culture' to expose NHS failings.[13]