The parents of a newborn girl who died at a scandal-hit NHS trust have told Sky News they believe there is a “systemic problem within midwifery” nationwide.

Rhiannon Davies and Richard Stanton lost their first child, Kate Stanton-Davies, in March 2009. She was born very unwell, but the warning signs weren’t picked up on until it was too late.

They described the findings published today of an inquiry into baby deaths and allegations of poor care at Shrewsbury and Telford Hospital NHS Trust (SaTH) as “truly shocking” and “heartbreaking, but very powerful”.

It found among several serious failings that mothers and parents were effectively blamed for what went wrong, women were given drugs to increase the frequency of contractions, and a lack of kindness and compassion from some members of the maternity team at the trust.

Independent midwife Donna Ockenden was originally asked to look at 23 cases of alleged maternity failings at the trust. Since the review began in 2017, she has been contacted by 1,862 families, with most of the incidents taking place between 2000 and 2019.

Ms Davies said a “core strong theme” within the findings was that mothers were encouraged to avoid cesarean sections.

She said the report showed “case after case after case” for a “push for a natural birth at seemingly any cost”, and cited examples in which babies were “aggressively delivered via forceps and having their skulls crushed and dying”.

Recalling her own labour, she said: “Right at the point of Kate being born… I remember saying, ‘I can’t do this’, and the midwife shouting at me.”

Mr Stanton said: “Rhiannon herself was blamed for the loss of Kate. The midwife said at the inquest that she couldn’t look after Kate because she was looking after Rhiannon just moments after the birth of Kate, and that was not fundamentally true – it was proven to be factually incorrect at inquest.

“But, within this review today, there are vignettes of stories… and some of them are truly shocking.

“There are illustrations of maternal deaths, the death of a mother during childbirth, where that case was never investigated… so the chances of that happening again were heightened. And it did happen again – 13 maternal deaths in a period of 18 years.

“Vignettes of mothers lying in agony and screaming out for pain relief but not being given it… an uncaring service – a service that doesn’t care for its patients.

“The findings of today’s interim review are truly shocking and are incredibly hard to read.”

He added: “There needs to be now, perhaps, a wider investigation as to who knew what and when, and what did they do to try and prevent this from happening?”

Ms Davies said: “Why did no one at the hospital trust speak out when they saw case after case after case of babies effectively being killed?”

She said she believes “there is a systemic problem within midwifery”.

“Midwives believe that they are experts in pregnancy, birth and neonates – that’s not the case. And that’s not to takeaway from midwives, they have an incredibly important role,” she said.

“They need to understand when to escalate – to escalate is not an admission of failure.”

She added: “I do feel there is a huge toxic culture in place at this hospital trust, but the issues of natural birth at any cost go across maternity in this country.”

The couple campaigned for the review into the NHS trust alongside Kayleigh and Colin Griffiths, who lost their baby daughter Pippa in 2016.

The review said the deaths of Kate and Pippa “were avoidable”.

Ms Ockenden said the care at the trust had “caused untold pain and distress, including, sadly, deaths of mothers and babies”.

The inquiry identified seven “immediate and essential actions” needed to improve maternity services across England, including risk assessments throughout pregnancy and monitoring fetal wellbeing.

Responding to the report, patient safety and maternity minister Nadine Dorries said she expected the SaTH to act on the recommendations immediately following the “shocking” failings.

West Mercia Police have also launched their own investigation to establish if there are any grounds for criminal proceedings.

Louise Barnett, chief executive at Shrewsbury and Telford Hospital NHS Trust, said: “I would like to thank Donna Ockenden for this report but more importantly the families for coming forward.

“As the chief executive now and on behalf of the whole trust, I want to say how very sorry we are for the pain and distress that has been caused to mothers and their families due to poor maternity care at our trust.

“We commit to implementing all of the actions in this report and I can assure the women and families who use our service that if they raise any concerns about their care, they will be listened to and action will be taken.”

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