Kate Stanton-Davies death: Investigation 'not fit for purpose'

Kate Stanton-Davies, pictured with her mother Rhiannon, was born at Ludlow Community Hospital

An investigation into the death of a baby born at Ludlow Community Hospital was "not fit for purpose".

Kate Stanton-Davies died six hours after her birth in March 2009 after being transferred to Birmingham's Heartlands Hospital.

An NHS England review said the death was avoidable and it could not be sure lessons had been learnt.

Shrewsbury and Telford Hospital Trust has apologised, saying it's a different organisation from six years ago.

'Put off request'

A supervisory investigation into the death, carried out by a midwife employed by the trust, established there had been no breach of care.

But following a complaint to NHS England by Kate's parents, independent expert Debbie Graham was commissioned to review the case.

She concluded the extent of weaknesses in the first investigation made it "invalid" and recommended NHS England looks at supervisory investigations conducted by midwives at other hospitals to see if there is a wider problem.

Her review raised concerns about events in the run-up to the birth not being investigated, including three opportunities to discuss with a consultant where the baby should be born and whether the midwife-led unit at Ludlow was appropriate.

The death could have been avoided if Kate had been born in a doctor-led unit, the review said.

'Open and honest'

Kate's mother Rhiannon Davies said: "We are shocked by how little Shrewsbury and Telford Hospital NHS Trust has done to date."

Sarah Bloomfield, director of nursing and quality at Shrewsbury and Telford Hospital NHS Trust, said: "It is of crucial importance that we are open and honest about our findings in relation to this review and in particular any further learning that is identified."

NHS England said it planned to take action, including a "robust" audit of midwifery supervisory investigations compliance.

The BBC understands three midwives have been suspended following the NHS England review. The trust said any disciplinary procedures had to remain confidential.