Rhiannon Louise Davies MBE and Richard Anthony Stanton MBE are married British activists who worked to establish the truth about the death of their daughter, Kate-Stanton Davies, at Shrewsbury and Telford Hospital NHS Trust in 2009. Their efforts led to the establishment of the Ockenden Review of maternity services, led by Donna Ockenden. Further, their campaigning led to West Mercia Police instigating Operation Lincoln into both individual and corporate gross negligence manslaughter at Shrewsbury and Telford Hospital NHS Trust.
In March 2009, 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 hospitalised 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 Heartlands Hospital in Birmingham. [1] [2] Though Kate was cremated, the Emstrey crematorium did not use settings appropriate for infants, so Davies and Stanton were told there were no ashes. [3]
Davies and 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, represented by the barrister Elizabeth Francis [4] of Atlantic Chambers. 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. [3]
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. [5] 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 Davies and 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". [6]
Davies and Stanton were both appointed Member of the Order of the British Empire (MBE) in the 2023 Birthday Honours for services to maternity healthcare, [7] [8] along with fellow campaigners Colin and Kayleigh Griffiths, [9] whose baby daughter Pippa died under the care of Shrewsbury and Telford Hospital NHS Trust in 2016. [10]
A home birth is a birth that takes place in a residence rather than in a hospital or a birthing center. They may be attended by a midwife, or lay attendant with experience in managing home births. Home birth was, until the advent of modern medicine, the de facto method of delivery. The term was coined in the middle of the 19th century as births began to take place in hospitals.
Caithness General Hospital is a rural general hospital operated by NHS Highland, located in Wick, Caithness, Scotland. It is managed by NHS Highland.
Liverpool Women's NHS Foundation Trust runs Liverpool Women's Hospital, a major obstetrics, gynaecology and neonatology research hospital in Liverpool, England. It is one of several specialist hospitals located within the Liverpool City Region; alongside Alder Hey Children's Hospital, Liverpool Heart and Chest Hospital, the Walton Centre, Mersey Regional Burns and Plastic Surgery Unit, and Clatterbridge Cancer Centre.
The Portland Hospital for Women and Children is a private maternity hospital on Great Portland Street, City of Westminster, London, England, owned by the Hospital Corporation of America.
The West Midlands Ambulance Service University NHS Foundation Trust (WMAS) is responsible for providing NHS ambulance services within the West Midlands region of England. It is one of ten ambulance trusts providing England with emergency medical services, and is part of the National Health Service.
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The Royal Shrewsbury Hospital is a teaching hospital in Shrewsbury, Shropshire, England. It forms the Shrewsbury site of the Shrewsbury and Telford Hospital NHS Trust, serving patients from Shropshire and Powys, in conjunction with the Princess Royal Hospital in Telford.
The Princess Royal Hospital is a teaching hospital located in Apley Castle, Telford, England. It forms the Telford site of the Shrewsbury and Telford Hospital NHS Trust and serves patients in Telford and Wrekin, the rest of Shropshire, and Powys, in conjunction with the Royal Shrewsbury Hospital.
East Kent Hospitals University NHS Foundation Trust is one of the largest hospital trusts in England. It runs the Kent and Canterbury Hospital (Canterbury), William Harvey Hospital (Ashford), Queen Elizabeth The Queen Mother Hospital (Margate), Buckland Hospital (Dover), and the Royal Victoria Hospital (Folkestone) – and some outpatient facilities in the East Kent and Medway areas in England.
The Furness General Hospital scandal involves an investigation by Cumbria Constabulary and other government and public bodies into the deaths of several mothers and newborn babies, during the 2000s at Furness General Hospital (FGH) in Barrow-in-Furness, Cumbria, England. Cases date back to 2004, with a number of major incidents occurring in 2008. The death of Joshua Titcombe and a suppressed report by the Morecambe Bay NHS Trust brought the spotlight onto FGH in 2011 when investigations began. Claims of medical records being intentionally destroyed alongside the discovery of major wrongdoing on behalf of midwives led to threats of closure to the maternity ward.
The National Health Service Reorganisation Act 1973 is an Act of the Parliament of the United Kingdom.
Shrewsbury and Telford Hospital NHS Trust is the main provider of hospital services for Shropshire, Telford and Wrekin and North Powys. It runs the Royal Shrewsbury Hospital, the Princess Royal Hospital in Telford, Oswestry Maternity Unit, and Wrekin Community Clinic, Euston House, Telford, in Shropshire, England. It is one of a small number of English NHS Trusts which takes patients from over the border in Wales.
One To One Midwives was an independent midwifery company founded by Joanne Parkington, a midwife in Birkenhead. The company was officially named One to One Ltd. On 29 July 2019, Joanne Parkington informed her staff the company would cease trading on 31 July 2019.
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James Roger Titcombe OBE is a patient safety specialist. He was previously, from October 2013 to March 2016, the National Advisor on Patient Safety, Culture & Quality for the Care Quality Commission.
Since the National Insurance Act 1911 there has been state involvement in provision of maternity services in the United Kingdom.
Donna Ockenden, is a British midwife and community activist. She was commissioned in 2016 by the then UK Secretary for Health and Social Care, Jeremy Hunt, to chair an independent review into maternity services at Shrewsbury and Telford Hospital NHS Trust. Initial findings of the Ockenden Review were reported in December 2020, with a final report published on 17 March 2022. In May 2022, it was announced by NHS England that Ockenden would chair an independent review of maternity services at Nottingham University Hospitals NHS Trust (NUH). This review commenced at the beginning of September 2022 and is expected to continue until late 2025.
In 2017 Rhiannon Davies, her husband Richard and two other bereaved parents, Kayleigh and Colin Griffiths asked the UK health secretary, Jeremy Hunt, to set up a public inquiry into maternity services at Shrewsbury and Telford Hospital NHS Trust. Though Hunt did not establish a public inquiry, he ordered a review in April 2017. In May 2017 Donna Ockenden was appointed chair of the review, and it initially investigated 23 cases of potentially significant concern.