Rhiannon Davies is a British activist who has worked with her partner , Richard Stanton, to establish the truth about the death of their child , Kate-Stanton Davies, at Shrewsbury and Telford Hospital NHS Trust in 2009. The efforts of Davies led to the establishment of the Ockenden Review of maternity services, led by Donna Ockenden, which reported  in December 2020.  Death of Kate Stanton-Davies In March 2009 Rhiannon 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 hospitalized after feeling unwell. However, midwives had not carried out any risk assessment or adjusted her birth plan. Kate was born cold and floppy, with anaemia. Midwives, not thinking anything was amiss, placed Kate in an unhearted cot  , and only called an ambulance two hours later. Kate died after being transferred to a Birmingham hospital.Victoria Macdonald, ‘A baby died an avoidable death’: one family’s fight for justice, Channel 4 News, 2 March 2015. Accessed 23 December 2020. Though Kate was cremated, the Emstrey crematorium did not use settings appropriate for infants. So Rhiannon and her partner Richard Stanton were told there were no ashes.Damien Gayle, 'They haven’t told the truth': parents denied children's ashes chase justice, The Guardian, 5 June 2015. Accessed 23 December 2020. Pursuit of the truth Rhiannon Davies and her partner Richard 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. The inquest jury unanimously found that Kate's delivery at a midwife-led unit contributed to her  death. They then secured the Health Service Ombudsman's attention to the case . 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. 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 misrepesenting the problem as a historic problem. 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 ven made to Kate's clinical observation notes after her death.Shropshire parents floored by findings of report into baby daughter's death, 24 February 2016. Accessed 22 December 2020. Later that year, 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 Ms Davies and Mr 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".Kate Stanton-Davies death: Trust 'failed to establish facts' around death, BBC News, 1 April 2016. Accessed 22 December 2020. Ockenden Review In 2017 Davies, Stanton and two other bereaved parents asked the UK health secretary, Jeremy Hunt, to set up a public inquiry into maternity services at Shrewsbury and Telford Hospital HNS Trust.Dominic Robertson, Parent involved in Shropshire baby deaths review, Shropshire Star, 4 January 2018. Accessed 22 December 2020. Though Hunt did not establish a public inquiry, he ordered an investigation in April 2017.Denis Campbel, Jeremy Hunt orders investigation into baby deaths at NHS trust, The Guardian, 12 April 2017. When published in December 2020, the  Ockenden Report singled out the difference made by Davies, Stanton and two other bereaved parents, Kayleigh and Colin Griffiths:
Rhiannon Davies is a British activist who has worked with her husband , Richard Stanton, to establish the truth about the death of their daughter , Kate-Stanton Davies, at Shrewsbury and Telford Hospital NHS Trust in 2009. The efforts of Davies led to the establishment of the Ockenden Review of maternity services, led by Donna Ockenden, which reported its initial findings in December 2020. A final report is due December 2021. Further, her campaigning led to West Mercia Police instigating Operation Lincoln into both individual and corporate gross negligence manslaughter at Shrewsbury and Telford Hospital NHS Trust. Death of Kate Stanton-Davies In March 2009 Rhiannon 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 hospitalized 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 unhearted 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 a Birmingham hospital.Victoria Macdonald, ‘A baby died an avoidable death’: one family’s fight for justice, Channel 4 News, 2 March 2015. Accessed 23 December 2020. Though Kate was cremated, the Emstrey crematorium did not use settings appropriate for infants. So Rhiannon and her husband Richard Stanton were told there were no ashes.Damien Gayle, 'They haven’t told the truth': parents denied children's ashes chase justice, The Guardian, 5 June 2015. Accessed 23 December 2020. Pursuit of the truth Rhiannon Davies and her husband Richard 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. The inquest jury unanimously found that Kate's delivery at a midwife-led unit contributed to her avoidable death. 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. 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 misrepesenting the problem as an historic problem. 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.Shropshire parents floored by findings of report into baby daughter's death, 24 February 2016. Accessed 22 December 2020. Later that year, 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 Ms Davies and Mr 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".Kate Stanton-Davies death: Trust 'failed to establish facts' around death, BBC News, 1 April 2016. Accessed 22 December 2020. Ockenden Review In 2017 Davies, Stanton and two other bereaved parents asked the UK health secretary, Jeremy Hunt, to set up a public inquiry into maternity services at Shrewsbury and Telford Hospital HNS Trust.Dominic Robertson, Parent involved in Shropshire baby deaths review, Shropshire Star, 4 January 2018. Accessed 22 December 2020. Though Hunt did not establish a public inquiry, he ordered an investigation in April 2017.Denis Campbel, Jeremy Hunt orders investigation into baby deaths at NHS trust, The Guardian, 12 April 2017. When published in December 2020, the first Ockenden Report singled out the difference made by Davies, Stanton and two other bereaved parents, Kayleigh and Colin Griffiths:
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child
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its initial findings
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A final report is due December 2021. Further, her campaigning led to West Mercia Police instigating Operation Lincoln into both individual and corporate gross negligence manslaughter at Shrewsbury and Telford Hospital NHS Trust.
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anaemia. Midwives, not thinking anything was amiss,
hyperthermia and anaemia. A midwife
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in a side room
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two hours later.
when a health care assistant found Kate in cardiac arrest.
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avoidable
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. The ombudsman
after Shrewsbury and Telford Hospital NHS Trust refused to accept the findings of the inquest. The Ombudsman
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first