Nottingham University Hospitals (NUH) NHS Trust has been fined £800,000 following the tragic death of baby Wynter Andrews.
The trust was criminally prosecuted by the Care Quality Commission (CQC), in one of only two such cases the CQC has brought against an NHS maternity unit. In addition to the fine, NUH NHS Trust will have to pay the prosecution costs of £13,668.65.
Passing sentence, District Judge Grace Leong said there were “systematic failures” in the care received:
“There were systems in place, but there were so many procedures and practices where guidance was not followed or adhered to or implemented”.
Wynter sadly died just 23 minutes after she was born by caesarean section in September 2019 at the Queen’s Medical Centre. An inquest in 2020 found she died from a loss of oxygen flow to her brain (known as hypoxic ischaemic encephalopathy).
The Nottingham County Coroner found that Wynter’s death was a “clear and obvious case of neglect” and that “gross failings” had occurred. It reported that “failure to provide safe care and treatment” had caused her death and this would have been entirely avoidable with the correct treatment.
The Court heard the CQC brought the charges after the trust’s mistakes meant Wynter and her mother, Sarah Andrews, did not receive safe care and treatment in its maternity services.
The Court was told a specialist obstetrician (commissioned by the CQC) raised a number of concerns in relation to Mrs Andrews’ care.
Concerns should have been noted earlier by the midwives on the day of Wynter’s birth and it was noted that the eventual birth took place past the 60-minute Caesarean section target set by the NHS. The expert also added there were issues with the systems and training used by the trust.
Concerns about maternity services in Nottingham
Maternity services at Nottingham University Hospitals Trust have been rated inadequate by the CQC since 2020 after a series of unannounced inspections prompted by comments from a coroner criticising the “unsafe culture”.
The CQC’s report found that staff were chronically overworked and “unable to raise concerns without fear”. The regulator also highlighted repeated failures of staff to use cardiotocography (CTG) equipment, which helps to monitor a baby’s heart rate during labour.
A review of the trust’s maternity units is currently underway, headed up by midwife Donna Ockenden “in light of significant concerns raised regarding the quality and safety of maternity services” by the families affected.
NUH NHS Trust admits maternity failures
The trust has admitted there were not processes in place to enable staff to manage all risks to patients’ health and wellbeing, which the CQC said exposed them to “a significant risk of avoidable harm”.
The trust has also admitted that it let the Wynter Andrews’ family down and that they have and will continue to put in place steps to improve the care provided.
Medical negligence solicitor Hannah Carr, who specialises in women’s health and pregnancy and birth claims, says:
“My thoughts are with the Andrews family and all those who have suffered the unimaginable loss of a baby. I echo their views that this prosecution should act as the catalyst for meaningful change. Until there is proper accountability and learning from these devastating maternity services mistakes, babies and mothers will continue to be harmed and lives lost.
“The gravity of this prosecution is indicative of the magnitude of improvement which Nottingham Maternity Services needs to implement. These vital changes will need to be urgently made before families will start to trust the hospital again and feel safe.
“Sadly, through our work supporting families we’re only too aware of the devastating consequences that maternity care failings can have, either through the loss of a much-loved child or when severe birth injuries are sustained.
“We can only hope that this prosecution will go some way in achieving the justice that is deserved and can – in part – help Wynter’s family to start to move on from this desperately sad and difficult time in their lives.”
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