Couple whose baby died at Ludlow maternity unit criticise review of service

Ludlow Advertiser: Rhiannon and Richard Stanton. Rhiannon and Richard Stanton.

A MOTHER whose baby died hours after being born at the maternity unit at Ludlow Hospital has dismissed a review of maternity services as a "PR exercise".

Rhiannon Davies, 39, and her partner Richard Stanton, 43, lost their baby, Kate in 2009. She died in hospital in Birmingham after being airlifted from Ludlow.

The review of maternity care was commissioned by the Shropshire Clinical Commissioning Group, partly as a result of the death of Kate and an inquest that was critical of her care.

The executive summary of the review states that its overall findings "demonstrate that this is a safe and a good quality service which is delivered in a ‘learning organisation’"

It concedes 8-10 per cent of service user feedback was negative and that areas for "growth and development" were identified.

But Rhiannon maintains there have been no significant changes since her baby died in March 2009, and that the review has failed to tackle the issue of clinical competency, something she has highlighted throughout.

She believes she should never have been considered suitable to give birth in a midwifery-led unit and that her daughter would have survived had she had appropriate care.

“We are dissatisfied with the conclusions of the maternity services review because we feel it fails to address any of the critical issues that are still affecting mums-to-be and their babies in the county – issues which first came to light for us when we lost our daughter in 2009,” she said.

Rhiannon claims the CCG has put a positive spin on the statistics which don't tell the whole story, but the CCG disputes this and states the figures have been independently assessed and are open to scrutiny.

"If you dig deeper you learn a quarter of mothers in labour midwifery-led units are transferred during labour to the consultant-led unit – that suggests things are going wrong," said Rhiannon.

She said this was an especially serious issue in rural areas like Ludlow and south Shropshire because of the distances and time it takes to get a mother to a consultant-led unit.

“There were 1,050 maternity patient safety episodes between April 2012-March 2013 – this included five deaths and four cases of permanent or long-term harm.”

"If you dig deeper you learn a quarter of mothers in labour midwifery-led units are transferred during labour to the consultant-led unit – that suggests things are going wrong," said Rhiannon.

She said this was an especially serious issue in rural areas like Ludlow and south Shropshire because of the distances and time it takes to get a mother to a consultant-led unit.

Rhiannon is critical of the review’s failure to reveal exactly where the more serious incidents have occurred, saying the CCG is “very careful not to break the data down by treatment centre.

So women delivering have no idea if any of the deaths and serious harm incidents were at their local unit.

“Here is a maternity service in crisis which had 23 serious incidents in the last year,”

But the CCG responded by saying all the 23 reported serious incidents were looked into.

A spokesman said: “After examination it was decided that only seven met the reporting criteria and the rest were not true serious incidents.

“As the number is so low identifying where each took place would breach information governance rules.

However MLUs are not over-represented in serious incidents or perinatal mortality and have nationally and locally been found to be safe.”

Rhiannon is also critical of the marketing strategy employed.

“Throughout we read there needs to be an active marketing campaign to promote maternity-led units to get more women to deliver there because they are more cost effective.

“This is putting money first and lives second. This is unacceptable.”

The CCG responded by stating the ‘hub and spoke’ model (consultant-led units and midwife-led units) – which is currently in place – “costs CCGs more than just having a consultant led unit.

The review was commissioned to look at quality, patient safety and experience and specifically not at the financial impact”.

In its conclusions the review states further work is needed to review neonatal admissions and says confidence needs to be built with regard to “the safe transfer of women and alleviating anxiety for those women who choose to book in a MLU and then need to be transferred to the consultant unit”.

Lastly on the key issue of clinical competence, which Rhiannon says has not been tackled, the CCG said: “All midwives employed at the trust are Nursing and Midwifery Council registered practitioners who meet the annual requirements to practice.

“Even today SaTH are running a ‘Stabilisation of the newborn’ course, which is part of on-going training, and is a direct outcome of the case of Kate Stanton-Davies.”

  •  Follow the link above to read the full report.

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