Special meeting will discuss independent maternity review

An independent Maternity Review was published yesterday. It 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.

In a statement, Simon Wright, Chief Executive of The Shrewsbury and Telford Hospital NHS Trust (SATH) said:

"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.

"The 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."

The Shrewsbury and Telford Hospital NHS Trust says it has 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

The review was published on the Trust’s website at www.sath.nhs.uk/independentreview.