Pictured: Rhiannon Davies and her daughter Kate
There were nights when Donna Ockenden, while working on her landmark review, would go back to her hotel room and cry. ‘I met several families a day, and I heard things that will stay with me for the rest of my days,’ the senior midwife tells Grazia. ‘There are stories I will never forget. A few weeks ago it was Mother’s Day, and when you sit with the family of a young mother who has died in childbirth, and meet her mother, her husband, the children she left behind, you feel terrible sadness.
‘I’m not ashamed to say that night after night, up in Shrewsbury, I would go back to my hotel, sit on my bed and cry. But the families I met entrusted me with giving those young mothers a voice, and that’s what I intend to do.’
Last month the Ockenden Report, the result of a five-year investigation into maternity care at Shrewsbury and Telford NHS Trust over a 20-year period, found more than 200 babies and nine mothers would have survived if not for the failings of the trust. The report found a reluctance to perform Caesarean sections despite risks to mother and baby (the trust’s C-section rate was eight to 12% lower than the national average), a bullying and cliquey culture among midwives, underfunding and understaffing, and a reluctance to investigate patient concerns. In some cases, mothers were lied to about why their babies had died. Two similar reviews are now underway in Nottingham and East Kent.
The Ockenden Report came about after Kayleigh Griffiths, whose daughter Pippa died in 2016, emailed fellow Shropshire mother Rhiannon Davies, whose daughter Kate died in 2009. ‘I hope you don’t mind me contacting you and I hope I don’t cause upset…’ Kayleigh’s email began. She had seen local reports about Rhiannon’s fight to uncover the truth about her baby’s death.
Rhiannon replied, and the two mothers went on to collect details of 23 cases of local stillbirths, neonatal and maternal deaths, and babies born with brain injuries in the care of the trust. (‘There were so many similarities, yet we were told that our stories were a one-off that would never happen again,’ says Rhiannon.) The mothers wrote to the then Health Secretary Jeremy Hunt in December 2016, and he ordered an investigation, appointing Donna Ockenden to lead it.
‘Kate was a very much wanted baby,’ Rhiannon tells Grazia. ‘In the final two weeks of my pregnancy, in February 2009, she went from being a super-active baby to one who stopped moving.’ Rhiannon went to the midwife-led unit to be told she had a ‘lazy baby’ and to go home and have a cold drink. ‘I began to feel very unwell, which we later discovered was Kate bleeding back into the placenta due to foetal-maternal haemorrhage. During labour there were also three heart decelerations. Just one is a red flag, but nothing was done. Kate was born pale, floppy, and began murmuring, but the midwife said she was just trying to cry. I’ve since had another baby who was born pink and screaming, but Kate was my first, so I didn’t know this was a sign of respiratory distress.’
It wasn’t until another midwife found Kate unresponsive that she was airlifted to Birmingham’s Heartland hospital (because a nearer hospital’s helipad was closed; at this stage Rhiannon and husband Richard had no idea where Kate was). After collapsing herself, Rhiannon was taken to another hospital and instructed Richard to find Kate. ‘He got a call from Heartlands who told him to get there quickly. When he arrived, he held Kate and she died in his arms. She was six hours old. When I finally arrived, I took her in my arms and I didn’t let her go.’
After a long fight, in 2016 the trust finally accepted responsibility for Kate’s death. ‘Richard and I thought, “That’s it, we’re done,”’ recalls Rhiannon. ‘They’ve learned their lesson. This will never happen again. Two months later, Pippa died.’
Pippa Griffiths was born in 2016 and struggled to feed, but when her mother Kayleigh spoke to midwives she was told not to worry, even when Pippa coughed up brown liquid. Despite several calls about Pippa’s breathing the night after her birth, she died the following day at just 31 hours old. The trust said they would carry out an internal investigation with no parental input necessary, but Kayleigh, an NHS auditor at another trust, sensed something was amiss and emailed Rhiannon.
The Ockenden Report later uncovered avoidable errors in both cases, along with ‘evidence of poor investigation’, and ‘a lack of transparency and dialogue with families’.
‘It is heartbreaking that this report only came about because of the determination of the families,’ says the Royal College of Midwives’ (RCM) chief executive, Gill Walton. ‘We owe them a debt I fear can never be repaid. The review has identified workforce shortages as being a threat to safety. The RCM has been highlighting this for over a decade, calling on three successive Health Secretaries to invest not only in recruitment but retention of midwives.
‘This review must be a turning point for all those working in maternity services. We all have a responsibility to speak up and speak out about poor behaviours and poor care in our workplaces. I’m asking midwives, maternity support workers, obstetricians and anyone working in maternity services to look around them and ask themselves, is the care being provided where you work safe? If it’s not, I need you to have the courage to speak up. This has to stop.’
‘We only spoke to 109 members of maternity staff,’ says Ockenden. ‘That’s a tiny number when you consider our review took place over a 20-year period. Some even withdrew their statements for fear of being identified. The report details “cliques on the labour ward” and “little gangs” that would “make your life hell” if you spoke out.’
Carley McGee, one of the 23 families in the report, gave birth to daughter Keeley in March 2010. Keeley’s lips and eyes kept turning blue, a sign of pneumonia, but midwives repeatedly told Carley not to worry. The next day, a senior and a trainee midwife visited the new family at home. ‘Keeley was still turning blue, and when the trainee midwife unbuttoned her babygro she said she felt cold and seemed floppy, but the senior midwife dismissed her and they left,’ Carley told Grazia. A few hours later, Carley’s mother insisted Keeley be taken to hospital. ‘But she died on the way. She was barely a day old,’ says Carley.
‘At the inquest, the senior midwife claimed I had Keeley dressed in shorts and T-shirts, and she had to tell me to warm her up. The trainee then got up and said Keeley was dressed properly, and that she’d tried to tell the senior midwife something was wrong after they left our house. The senior midwife fled the room crying at this point. The trainee was so brave to speak out, but the senior midwife is still working. I can’t put into words the anger I felt that day. Then Kayleigh got in touch and, for the first time, I felt like somebody was actually listening to us.’
‘I hope women will now feel heard when they speak up,’ says Ockenden. ‘Our families asked for two things – to understand why their baby died, with many being told half-truths or untruths. And to know it wouldn’t happen again. We set out 15 immediate and essential actions in our report, which is a blueprint for safe maternity care, and we will keep pushing to ensure they happen.
A generation of women were silenced by the system, but that won’t happen again because of the bravery of those who came before them.’
‘In her six hours of life, Kate achieved more than most of us will in a lifetime,’ says Rhiannon. ‘I’ve done this for her. And for all the other babies who should be with us now.’
Louise Barnett, chief executive at The Shrewsbury and Telford Hospital NHS Trust, said, ‘[The] report is deeply distressing and, on behalf of all at the trust I offer our wholehearted apologies for the pain and distress that has been caused.’
For support and information about baby loss, visit tommys.org and sands.org.uk