Maternity failings at Nottingham University Hospitals NHS Trust

Over the last decade dozens of babies have died or been left with brain damage at one of the UK’s largest hospital trusts, which has been accused of poor care and neglect.

Maternity failings

A joint investigation by The Independent and Channel 4 News revealed that from 2010 to 2020, 19 babies were still born and at least 46 have suffered brain damage at Nottingham University Hospitals (NUH) NHS trust maternity units. Furthermore, there have been a total of 15 deaths at the units involving mothers and babies.

According to the report, managers have failed to properly investigate concerns and even altered reports to take blame away from the maternity unit, with parents forced to fight to find out the truth about the circumstances surrounding their child’s injuries.

As well the poor care of both mothers and babies at NUH, the investigation found evidence of repeated failures to investigate baby deaths at the Queen’s Medical Centre and Nottingham City Hospital. Evidence of poor record-keeping and a failure to refer deaths to the coroner was also found.

Data from NHS Resolution - the government compensation and arbitration body – shows a total of 201 claims were made against the trust between 2010 and 2020. 84 of those claims have been settled, with a total of £91million paid out in compensation during the ten-year period. Cases involved:

• Accusations of a “failure or delay to treatment” in 25 incidents and on 13 occasions there were
• Accusations of a “failure to recognise complications” on 13 occasions
• 10 cases involving inadequate nursing care

The NHS Resolution data also revealed that as of last year, NUH (which has one of the largest NHS budgets in the UK) was facing at least a dozen clinical negligence claims by bereaved families.

Serious untoward incident

Harriet Hawkins was still born in 2016 at one of the trust’s hospitals. Her mother Sarah Hawkins, who was a senior physiotherapist for NUH when she gave birth to Harriet, is now calling for an independent inquiry. She told Channel 4 News:

“We were banging on the door saying ‘something’s wrong, babies are dying, and they shouldn’t’, and they didn’t listen, and they haven’t listened.”

Ms Hawkins was in labour for five days, something which she says should have alerted staff that there was a problem. An investigation into Harriet’s death found that her mother had been administered a high - and inappropriate - dose of pain relief drug diamorphine and there was a delay in monitoring the foetal heart. Furthermore, information was not recorded or passed on as it should have been.

Tragically, Harriet died before she could take her first breath. NUH only declared a serious untoward incident 159 days later, after which an external review was commissioned.

“I trusted them. They didn’t listen to me,” Ms Hawkins said. “It’s been horrific. It’s so exhausting. The trust haven’t been open or honest.”

She added: “I’d love the trust to have this guilt [that I feel]. Other babies have died since Harriet, and we are the ones here trying to improve things. I wish they would accept that.”

A spokesperson for NUH said that the trust has “recognised on a number of occasions” that there were “deficiencies” in Ms Hawkins and Harriet’s care, and they are “committed to learning from that and improving”.

Gross failings

In another harrowing case, an inquest found that “gross failings” contributed to the death of Wynter Andrews, who was born and died on the same day in September 2019.

The same inquest heard that the maternity unit at the Queen’s Medical Centre operated in a “fundamentally unsafe manner” and was understaffed on the day Wynter died.

Sue Brydon, a former senior midwife at NUH, has spoken out against the way in which the maternity units were run, with managers at Nottingham City Hospital acting as a “Teflon team” who failed to listen to staffing concerns. She added that the unit operated under a “culture of fear”.

According to Ms Brydon vacancies were allowed to accumulate, meaning staff were often stretched. A lack of beds also meant at-risk women would face delays for treatment.

Serious concerns

In October 2020 “several serious concerns were identified” by the Care Quality Commission (CQC) following an inspection into the maternity units at NUH. The units were given an “inadequate” rating and the trust was served with a “warning notice” after the health watchdog found poor risk management – a threat to mothers’ and babies’ safety.

Some improvements had been made by May 2021 when the CQC returned for another inspection, but some areas still needed to be addressed to ensure the trust “comprehensively manages all risks to people’s safety”.

The trust chief executive Tracy Taylor has apologised to families and said that improving maternity services was a “top priority” for the trust. She said:

“We apologise from the bottom of our hearts to the families who have not received the high level of care they need and deserve, we recognise the effects have been devastating.

“Improving maternity services is a top priority and we are making significant changes including hiring and training more midwives and introducing digital maternity records.

“We will continue to listen to women and families, whether they have received excellent care or where care has fallen short; it is their experiences that will help us to learn and improve our services.”

Gill Edwards, a partner in the Clinical Negligence team here at Potter Rees Dolan, is a birth injury claims specialist and a member of the Multi-Professional Advisory Panel of the mother and baby charity Baby Lifeline. Gill comments:

"When poor maternity care comes to light at one NHS Trust it is a tragedy for all involved, but we reassure ourselves that the Trust in question had unique issues, perhaps due to the practice and culture on the Unit, for example at Morecambe Bay. But it is distressing when it becomes clear that these issues are far from isolated and that there is something fundamentally wrong with maternity services at a number of Trusts across the country. Independent reports are already awaited into what went wrong at Shrewsbury & Telford Trust and East Kent Trust; and now we hear of similar issues at Nottingham University Trust.

"The long struggle described by families to find honest answers to what went wrong with their maternity care is very familiar to me as someone who represents claimants in clinical negligence. It is astounding that there has been such a catastrophic failure to learn lessons from previous tragedies and there needs to be a wholesale review of how information is shared between Trusts. Clinical negligence claims are often the only way for families to obtain answers and bring people to account for what went wrong. They also bring the pattern of failings to light and the Defendant body representing Trusts, NHS Resolution, has a mine of information which needs to be better utilised for shared learning.

"The whole system is too fragmented. Focussed training to prevent the mistakes which cause harm is offered by the mother and baby charity Baby Lifeline, but many Trusts are underfunded and understaffed. The same issues arise again and again, including the failure to interpret CTG traces correctly and the apparent desire to ensure a ‘normal’ delivery at all costs. I echo Jeremy Hunt’s call for an independent inquiry into the events at Nottingham but the Health and Social Care Committee inquiry into the safety of maternity services across the whole of England needs to be ramped up as a priority".

To speak with Gill or any other member of our Clinical Negligence team with regards to birth injury and medical negligence claims, call us today on 0800 027 2557. Alternatively, contact Gill directly here.