Scandal-hit Nottingham University Hospitals NHS Trust has been fined a record £1.6 million after pleading guilty to six offences relating to the deaths of three babies under their care.
The trust was charged by the Care Quality Commission (CQC) of failing to provide safe care and treatment to Adele O’Sullivan, Kahlani Rawson and Quinn Parker who all died shortly after birth within a 14-week period in 2021.
During the hearing at Nottingham Magistrates Court on Monday 10th February, the court was told how serious and systemic failures exposed all three mothers and their babies to significant risk of avoidable harm.
The trust admitted all six charges relating to the deaths and offered ‘profound apologies and regrets’ to the families involved.
At a sentencing hearing on Wednesday 12th February, district judge Grace Leong handed down a historic fine of £1.6m. This was reduced from £5.5m, taking into account the trust's financial position and guilty pleas.
This is the second time that NUH has been fined for maternity failings. They were fined £800,000 in 2023 for a catalogue of errors that led to baby Wynter Andrews’ death in September 2019.
They are also at the centre of the largest maternity inquiry in NHS history, while Nottingham Police Force is conducting its own criminal investigations into the failings.
Here we look at the issues affecting the troubled NHS trust.
What’s happened at Nottingham NHS Trust?
Nottingham University Hospitals NHS Trust (NUH) runs the City Hospital and Queen’s Medical Centre.
NUH’s maternity service was rated ‘Inadequate’ by the CQC in December 2020 following an inspection in the October. The regulator found a number of issues including:
- Staff hadn’t completed training in key skills
- Repeated issues with foetal monitoring
- A lack of adequate systems and processes, or procedures not being implemented
- Staff not always understanding how to keep women and babies safe
- A lack of communication between staff during shift handovers
- Limited evidence of managers monitoring effectiveness of care and treatment
Since then, another inspection in September 2023 found that some changes had been implemented such as:
- Improved foetal monitoring
- Guidelines and protocols updates and made more accessible for staff
- Handover processes improved
- Recruitment of more midwives to improve staffing levels
- Existing staff undergone more training
The rating was increased to ‘Requires Improvement’.
The largest maternity inquiry is ongoing
Both maternity departments are under investigation after hundreds of babies died or were injured while under their care between 2010 and 2020. During that time period, there were 46 cases of brain damage and 19 stillbirths.
In the summer of 2022, former midwife Donna Ockenden was appointed to lead the independent inquiry into maternity failings at the trust. She had recently finished another inquiry into similar failings at Shrewsbury and Telford NHS Trust.
By the following July, the inquiry had become the UK’s largest, looking into the cases of 1,700 families. This has since increased further to over 2,000 and is expected to reach 2,500 by the time the review of new cases ends in May this year.
The scope of the inquiry was expanded in May last year to include all neonatal care, not just those cases of stillbirths, neonatal deaths and injuries.
Due to the number of cases, publishing of the report has been delayed by a year and is now set to be released in June 2026.
Cases that have come to light
There have been many high-profile cases that have emerged from the Nottingham maternity scandal.
Harriet Hawkins
This is first case that brought the systemic failures to light. Harriet was stillborn at 41 weeks. Her parents both worked for NUH, her father as a consultant and her mother a senior physiotherapist.
A hospital review found ‘no obvious fault’ and determined Harriet died of an infection. However, the parents pushed for an external review which found 13 failings in the Hawkins’ care including a delay in foetal monitoring and failure to follow risk management policies. The review concluded that Harriet’s death was almost certainly preventable. The family received £2.8m in compensation from the trust.
Wynter Andrews
Wynter died in September 2019, 23 minutes after she was born via c-section due to a lack of oxygen to her brain. At Inquest, the coroner said there was ‘a clear and obvious case of neglect’. A letter from midwives on the unit to NUH bosses, dating back to 2018, was used as evidence. It outlined concerns over staffing levels as ‘the cause of a potential disaster’.
Following Wynter’s death, the CQC brought their first charges against the trust, resulting in a fine of £800,000.
Three recent cases from second fine
This second fine of £1.6m relates to the deaths of three babies who died between April and July 2021. All three cases hold similarities as the three mothers experienced bleeding and abdominal pain caused by placental abruption.
Adele O’Sullivan’s mother Daniela had a high-risk pregnancy but she was not examined for eight hours before her daughter was born, despite presenting with vaginal bleeding and abdominal pain. Adele died 26 minutes after being born via an emergency c-section.
In a statement read out in court, Ms O'Sullivan said staff ignored her medical history and left her screaming in pain. "My daughter lost her life because of a lack of medical attention for many hours. People who were supposed to help me didn't help but harmed me, physically and mentally, forever. I lost my trust in the whole system.”
Kahlani Rawson’s mother Ellise also had abdominal pain and no foetal movement for 24 hours. CTG scans were misinterpreted by staff, resulting in a delay in her having a caesarean section. Her son suffered a brain injury and died at four days old.
Quinn Parker’s mother Emmie went into hospital with vaginal bleeding four times before her son was born. She had lost 1.2 litres of blood, but communication errors between paramedics and midwives meant the maternity team wrongly believed the blood loss to be 200mls. By the time he was born by emergency C-section, he was pale and floppy and died a day later. Quinn would have survived had a caesarean section been performed earlier.
Ahead of the court hearing, NUH chief executive Anthony May said: “The mothers and families in these cases have had to endure things that no family should after the care provided by our hospitals failed them, and for that I am truly sorry.
“The Trust recognises the concerns raised by the CQC and has acted upon them to improve the services we provide to women and families in our care. The changes made mean that we are working in a different environment than 2021 and we believe that we now have a safer and more effective maternity service.”
The cost of maternity failings
The NHS has already paid out over £100m in compensation to 134 families affected by negligent maternity care at Nottingham between 2006 and 2023.
Around £53m has been paid for cerebral palsy claims, £5.6m for bowel or bladder injuries to the mother, £4.6m for stillbirth claims, and £1.9m for maternal or neonatal death claims.
With up to 2,500 cases under review, there will no doubt be more cases where families sue the trust for medical negligence compensation.