Nottingham University Hospitals (NUH) NHS Trust has been fined £800,000 after pleading guilty to two charges related to the death of an infant and the poor care of its mother at the trust's Queens Medical Centre in Nottingham.
Passing sentence on Friday, District Judge Grace Leong said there had been "systematic failures" in care.
The Care Quality Commission (CQC) announced last July that it was prosecuting the trust over admitted mistakes which led to Sarah Andrews, and her baby, Wynter Andrews, not receiving safe care and treatment by its maternity services.
Wynter died shortly after her birth in September 2019.
An inquest the following year found that Wynter died from hypoxic ischaemic encephalopathy, which could have been avoided if staff had delivered her earlier. Assistant coroner Laurinda Bower found the baby's death "was contributed to by neglect" at the hands of NUH NHS Trust.
Court Case
During the case at Nottingham Magistrates' Court, the trust admitted it did not ensure safe maternity care and treatment for Sarah and Wynter, due to a lack of adequate processes and systems to ensure staff managed all risks to patients' health and wellbeing. This exposed both mother and daughter to a significant risk of avoidable harm, which constituted breaches of regulations 12 and 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Passing sentence today, the judge said: "The catalogue of failings and errors exposed Mrs Andrews and her baby to a significant risk of harm which was avoidable, and such errors ultimately resulted in the death of Wynter and post-traumatic stress for Mrs Andrews and Mr Andrews.
"My assessment is that the level of culpability is high, where offences on Wynter and Mrs Andrews are concerned.
"There were systems in place, but there were so many procedures and practices where guidance was not followed or adhered to or implemented."
It is understood that the full fine after a trial could have been £1.2 million, but this was reduced to £800,000 because of the trust's early guilty plea.
The trust will also pay prosecution costs of £13,668.65 and a victim surcharge of £181.
'We Are Truly Sorry'
Following Wednesday's hearing at Nottingham Magistrates' Court, the trust's chief executive Anthony May apologised and said: "We are truly sorry for the pain and grief that we caused Mr and Mrs Andrews due to failings in the maternity care we provided. We let them down at what should have been a joyous time in their lives. Today, we pleaded guilty and will accept, in full, the findings of the court.
"While words will never be enough, I can assure our communities that staff across NUH are committed to providing good quality care every day and we are working hard to make the necessary improvements that are needed for our local communities, including engaging fully and openly with Donna Ockenden and her team on their ongoing independent review into our maternity services."
Mr May added that since Wynter's death, the trust has implemented a number of changes to its maternity services, including:
- Improved access to clinical guidelines with the introduction of the Pocket Pal app for maternity staff and aligned Trust guidelines with national recommendations where available
- Implemented BadgerNet, a maternity digital clinical system to support seamless care across all parts of the pregnancy pathway
- Investment in staff training for obstetric emergencies, foetal heartbeat monitoring and human factors
- Investment in equipment, including foetal heartbeat monitoring machines and devices to measure jaundice in babies
- Introduced foetal monitoring leads for midwifery and obstetrics, tasked with supporting the team to follow best practice
- Strengthened the senior clinical team, appointing more consultant obstetricians and providing better cover across our two hospitals
- Ongoing recruitment of midwives, including from overseas and the appointment of two heads of midwifery
- Focus on retaining midwives, offering the option to work flexibly to suit their needs
- Introduced a flow coordinator role to support the maternity service 24 hours a day, seven days a week
- Separating our emergency and routine assessments at both hospitals, leading to over 90% of our women and families being seen in triage within 15 minutes
- Launched a 24/7 Maternity Advice Line, so anyone using our service can speak to a dedicated midwife about any concerns before or after birth
- Ongoing improvement of our staff feedback service and encouraging colleagues to raise any concerns through our Freedom to Speak Up Guardians and through other channels
- Improving record-keeping, including the assessment of risks and handovers between midwives and medical staff
- Developed a comprehensive Maternity Improvement Programme, overseen by the Maternity Oversight Committee, led by one of our Non-Executive Directors
- Developed a maternity dashboard to identify themes and trends in activity, clinical incidents and staffing to ensure better oversight of the service
Already Under Fire
As previously reported, NUH NHS Trust is already under investigation over serious failures in its maternity services, where dozens of babies died or were brain damaged due to care failures in recent years.
Last May, NHS England confirmed the appointment of Donna Ockenden as chair of a new independent review into maternity services at the trust, following its original decision in November 2021 to launch an independent thematic review. Ms Ockenden led the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust, the damning final report of which was published last year.
The more recent CQC inspection reports on Nottingham City Hospital and Queen's Medical Centre, led to the trust being ordered to make "significant and immediate improvements" to the two maternity services. Both services remain rated as 'inadequate'.
This article contains information from PA Media.
