Last month, the Ockenden report, the result of a five-year investigation into maternity care at Shrewsbury and Telford NHS Trust, 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 caesareans, a bullying culture among midwives, underfunding, understaffing, and a reluctance to investigate patient concerns.
Rhiannon Davies, one of two mothers who initiated the report, became pregnant with her daughter Kate in 2008. 'She was a very much wanted baby,' Kate tells Grazia.
'In the final two weeks of my pregnancy, in February 2009, Kate went from being a super active baby to one who stopped moving. I went to the midwife-led unit who told me I had a “lazy baby”. I then 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 and floppy, which is a sign of respiratory distress, but again nothing was done.'
It wasn’t until another midwife found Kate unresponsive that she was airlifted to Birmingham’s Heartlands Hospital, where she died at just six hours old.
After a long and unwavering fight, in 2016 the Trust finally accepted responsibility for Kate’s death. ‘My husband Richard and I thought, “that’s it, we’re done”,’ remembers Rhiannon. ‘They’ve learnt their lesson. This will never happen again. Two months later, Pippa died.’
Pippa Griffiths was born in 2016 and died at just 31 hours old, despite her parents Kayleigh and Colin's concerns about her feeding and breathing. Kayleigh made repeated calls to midwives the night after Pippa was born, only to be told nothing was wrong. The Ockenden report came about after Kayleigh emailed Rhiannon after seeing local newspaper reports about Rhiannon’s fight to uncover the truth about Kate's death.
‘Our voices have finally been listened to after being ignored for so long,' says Rhiannon. 'The emotional and literal cost has been huge, but I didn’t have a choice, I had to fight. I did it for Kate, who in her six hours of life achieved more than most of us achieve in a lifetime.’
Here, some of the other mothers who fought for justice share their stories.
‘They told us it was her heart'
Julie Rowlings went to Shrewsbury Hospital in May 2002 to have her first child.
‘After 23 hours in labour, a doctor used a ventouse (a suction device), which came off with a loud pop. Instead of a C-section, he then tried forceps, but they came off with a loud clang. On the second attempt he had his foot off the floor and was leaning back due to the force he was using. My husband had to hold me under my arms to stop me sliding down the bed.
‘Our daughter Olivia was born, but there was complete silence. She didn’t make a sound. In fact, she never made a sound again. They whisked her off, and the midwives told us she was very poorly. Hours later we still hadn’t been told anything, so my husband found a wheelchair and wheeled me up to see her. We found her covered in tubes, and they told us it was her heart.
‘My husband’s sister and her husband, both paramedics, turned up shortly afterwards and asked to see her. They came out and said, “It’s not her heart.” They could read the monitors and said her heart was absolutely fine.
‘We were told things were bad, so had her baptised, and I held her as I said goodbye. A tiny bit of her hair was poking out of her pink bonnet, so I lifted it up slightly and realised it was covered in blood. I gently took the bonnet off and found a huge bruise on her head.'
Olivia’s autopsy found several fractures to her skull, and every one of her major organs had haemorrhaged. 'Her acid levels were also through the roof,' says Julie. 'This meant she was in a lot of pain, which was the hardest thing for me to hear. You never want to think of your child in pain, do you?
‘We took the doctor to court for gross negligence and manslaughter, where we found staff statements didn’t match medical records. Despite this, they found the doctor not guilty and he’s still practising today. By this point, we stopped fighting. It was putting so much strain on our family, we tried to get on with our lives. Then we got the letter about Donna’s report, and I thought, I’ve got to continue the fight.
‘There aren’t enough lifetimes to thank Donna Ockenden. She listened, she was compassionate, and she promised us that if something was to be found, she would find it. If something needed changing, she would change it.'
The report found severe failings in Olivia’s care.
‘Grieving for a child that should be here is very hard,' says Julie. 'Olivia’s death was avoidable. After the ventouse came off, I should have had a C-section. Olivia never opened her eyes and never made a sound. Donna has given her a voice at last.’
‘The midwives heard her cry and joked her lungs were healthy'
Carley McGee’s daughter Keeley was born on 20 March, 2010. There were no concerns through her pregnancy, but during labour Keeley’s heart rate kept dipping and when she was born lots of people swarmed into the room. 'She needed oxygen for about a minute, but everybody told me she was fine after that,' says Carley.
‘After she was born, Keeley kept having “blue” episodes, where the area around her lips and eyes turned blue, but the midwife told us not to worry. They said it was because she was so young but it's actually a sign of pneumonia. They never checked her oxygen levels again after giving her oxygen right after birth.’
The next day, a senior midwife and a trainee midwife visited Carley at home, where she mentioned the blue episodes but was again told not to worry. ‘The trainee midwife, however, held Keeley, unbuttoned her babygro and said she felt cold and seemed limp. The senior midwife dismissed her.'
Shortly after, the new family visited Carley’s parents and her mother witnessed one of Keeley’s blue episodes. ‘My mum flew off the handle and said, “I’ve had four children and I know this is not normal. You need to take her to hospital right now",' remembers Carley. 'We called the hospital to tell them we were bringing her in and Keeley was crying in the background. They joked, “Well there’s no need to worry about her lungs by the sounds of it!”
‘She didn’t even make it to hospital – she died on the way. She was barely a day old. And it was her lungs. It was neonatal pneumonia, which is curable if spotted early enough. The joke they made sticks with me to this day. They just dismissed me the whole time.
‘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, including after they'd 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 listening to us.’
Eleven days before what would have been Keeley’s first birthday, her father Steven McGee, a soldier, was killed in Afghanistan. 'So this wasn’t just my fight,' says Carley. 'I was fighting on Steven’s behalf too because I know if he was still here he’d fight for his baby girl the whole way.’
'Mistakes happen - but I wanted them to learn from them'
One of the earliest cases on the original list of 23 families was Sonia Leigh's daughter Kathryn, who was born in 2000. ‘Our eldest son Michael had cancer when he was very young, and when we got the all clear he desperately wanted a brother or sister,’ Sonia tells Grazia. ‘When he was four, I became pregnant with Kathryn and we were over the moon.’
Sonia had an emergency caesarean with Michael, but was encouraged by Shrewsbury Hospital to have a natural labour. ‘I was quite happy with that, even though I was considered high risk because I’d had a blood transfusion after Michael’s birth, which had given me faulty antibodies that rejected pregnancies,' says Sonia.
The labour was long and Sonia failed to dilate after reaching 8.5cm due to a tilted pelvis. The same thing had happened with Michael and she needed another emergency C-section after all. 'As the obstetrician lifted Kathryn out, she dropped her back in and she swallowed fluid. She was pale and floppy by this point, so they began to resuscitate her, but the doctor used the resuscitation equipment incorrectly and she died 21 minutes after being born.
‘Not knowing about the second error, I started blaming myself, thinking it was the antibodies,’ says Sonia. ‘They gave us a chance to hold her. We also let Michael come in and hold her and say goodbye, because he was so looking forward to holding his new baby sister.’
The next day a tearful consultant came by Sonia’s bed and admitted one of his team had made a gross error. I was devastated, but I remember saying, “It’s OK, mistakes happen, she would have been slippery.”
'We then discovered the second error, but the three doctors involved covered for each other and said they didn’t know who had made the final, fatal, mistake. That’s when it hit me something was wrong.
‘We were advised to sue, so it wouldn’t happen again, but how could I sue the NHS when they’d saved Michael’s life just a few years before? I owe everything to the NHS, but I was told if I didn’t do it, change wouldn’t happen.’
At the inquest into Kathryn’s death, the trust admitted error but refused to accept criticism of its maternity care. They tried to blame her death on the equipment, but during the trial Sonia learned it’s not mandatory for doctors to attend equipment training.
‘Who is above training?’ says Sonia. ‘If I get a new computer system I have to be trained, so why does a doctor get away with not turning up to training that could be life-saving?'
The inquest recorded the death as misadventure.
‘In 2016 Kayleigh Griffiths contacted us and we met with Donna. I thought it would be this small investigation, but what began as 23 families quickly grew into the hundreds. We all thought we were the only one. I never wanted anybody to go to jail or even lose their job over this. I just wanted them to own up to and learn from their mistake.'
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.’