Ludlow baby death: End to couple's 'torturous' nine year wait for justice
A Shropshire couple today welcomed a ruling that a midwife should be struck off over a catalogue of serious failings in the care of their baby, who died just six hours after she was born.
The Nursing and Midwifery Council panel ruling centred on the actions of midwife Heather Lort during the delivery and care of Kate Stanton-Davies, who was born with anaemia at Ludlow Hospital on March 1, 2009.
It concluded that Lort's misconduct was so serious that it led to a loss of chance of survival for Kate, who died a matter of hours after she was born, after being airlifted to Birmingham's Heartlands Hospital.
The hearing had also been told that Lort, who was employed by Shrewsbury & Telford Hospital NHS Trust (SaTH), had admitted serious failings in her care of another baby who was stillborn in 2013.
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The panel said that the only way to prevent a repeat of Ms Lort's misconduct was to strike her off.
The decision to issue a striking off order comes nine years and eight months after Kate's death.
Kate's parents Rhiannon and Richard said the wait had been "torturous" but that the ruling finally provided justice for their daughter.
Ms Davies said: "I am pleased with the sanction because it is the only fair one for Kate."
She added that Ms Lort had "never said sorry" for her failings in Kate's care.
Ms Davies said she would not want any other family to have to go through the same kind of lengthy battle for justice.
She said: "I feel sorry for any other family having to go through it because you suffer so much in those early years."
She added that she was pleased they had fought to ensure that the tribunal went ahead.
She said: "It was the right thing to do and there was no way I would ever give up until I got justice for Kate.
"If I had I would be failing her all over again and I will keep fighting so every other family has a voice as well."
Mr Stanton said the nine and a half year wait had put him and Ms Davies through hell.
He said: "I am dismayed that it has taken so long. It should not have taken so long, she should have been thoroughly and properly investigated in 2009 after we lost Kate and that investigation could have presented the facts to the NMC and she could have been suspended.
"When the verdict was read out today and it was confirmed that the panel was striking her off it just vindicated everything me and Rhiannon have been through to make sure this hearing took place."
Mr Stanton said the findings raised serious question marks over why Ms Lort was allowed to continue working as a midwife in the years following Kate's death.
He said: "Why was a hands on clinician allowed to continue practicing unchecked when the NMC have found she was a danger to the public she served?"
Lort had admitted a series of charges at the tribunal, however, a number of other charges were ruled on, and were found proven by the panel.
It found she had not accurately recorded Kate's heart rate between 8.45am and her birth at 10.03am, and did not increase surveillance of the rate at 9.40am and 9.50am when decelerations were recorded.
The panel concluded that Lort had failed to arrange an emergency transfer when Kate was born 'pale and floppy', and then when she was found to be 'grunting' at 10.30am, until her collapse.
Other charges included failing to put Kate in an incubator when her temperature did not improve with skin to skin contact, and not providing effective resuscitation because she stopped before Kate's heart rate reached 100bpm, and before her care was transferred to "an appropriate practitioner".
She also failed to accompany Kate when she was transferred to the neonatal unit, or provide an adequate handover to paramedics.
Apology
In a statement Sarah Jamieson, head of midwifery at Shrewsbury and Telford Hospital NHS Trust (SaTH) offered an unreserved apology for the way it handled investigations into the standards of Ms Lort's care.
She said: “We appreciate the pain families involved in these tragic events have felt and continue to feel and we are sorry that they were let down whilst in our care.
“We have acknowledged that the initial investigations carried out in relation to midwife Heather Lort fell far short of what we would expect and what the families concerned deserved.
"I would like to take this opportunity to reiterate our unreserved apology for this. Our practice today is very different.
“Ms Lort was subject to a later investigation which resulted in her suspension. The conclusion of this investigation would have resulted in her dismissal. However, following her suspension Ms Lort retired from the Trust.
“The outcome of that investigation was passed on to the Nursing and Midwifery Council (NMC).
“We have subsequently checked records for Ms Lort and are not aware of any other incidents in which concerns have been raised. We would, however, encourage any families with any questions to contact us by emailing sath.womenandchildren@nhs.net.”
Avoidable
An independent NHS investigation into Kate's death, which was published in 2016, had detailed a series of damning findings about her care, and SaTH's handling of the investigation.
The report revealed that clinical notes for Kate were changed after her death and the original records did not match an electronic copy.
It said there was “no explanation” for the discrepancy.
The report also concluded there were “system issues” at the midwife-led unit in Ludlow, including no easily accessible policy for safe staffing levels and planned capacity at the time of Kate’s birth.
A jury inquest in 2012 and an investigation by the Parliamentary Health Service Ombudsman in 2014 both concluded Kate’s death was avoidable and the result of serious failings in care.
The inquest found that Kate would have survived if she had been born elsewhere and that the original classification of the pregnancy as low-risk was a contributory factor in her death.
However, a subsequent investigation was branded "not fit for purpose", sparking the 2016 report.
The review also found that SaTH had let Kate's parents down by not investigating her death adequately.
The report said the trust “failed to fulfil its responsibility to establish the facts of this case and to establish accountability”.
It said hospital bosses failed to properly investigate Kate’s death, failed to hold staff to account and failed to address concerns raised by Ms Davies and Mr Stanton.
Following the report at an extraordinary meeting of SaTH's board where Kate's parents spoke for more than 20 minutes, the trust's chairman Professor Peter Latchford said: “I am personally ashamed of the things you say we should be ashamed of. I am ashamed.
"This should be a defining moment in this organisation’s history. I think there is some evidence the journey has started, but I don’t want to over-proclaim that comment.”
