The mother of a baby who died in hospital just 23 minutes after being born has said she was “failed in the most cruel way” by an NHS Trust.
Nottingham University Hospitals NHS Trust put Wynter Andrews and her mother Sarah Andrews at “significant risk of avoidable harm”, a court heard on Wednesday.
Ryan Donoghue, prosecuting, said the trust was understaffed and failing to ensure staff at the Queen’s Medical Centre in Nottingham were aware of its own guidelines, culminating in Wynter’s death on 15 September 2019.
The infant died in the arms of her mother and father Gary Andrews, 23 minutes and 30 seconds after being born by emergency caesarean section.
At a hearing at Nottingham Magistrates’ Court on Wednesday, the trust pleaded guilty to two counts of being a registered person which failed to provide care and treatment in a safe way, resulting in harm or loss.
Speaking outside court alongside the family’s solicitor, Mrs Andrews said: “As first-time parents, all we ever wanted was to bring our precious baby home.
“Management at the trust were repeatedly warned by staff about safety at the unit, but they failed to act.
“They were repeatedly warned by bereaved and harmed families, but they failed to listen and to learn.
“They were repeatedly told by different investigative bodies over many years about maternity safety concerns at the trust, yet they failed to make the critical changes needed,” Mrs Andrews continued.
“We hope that this criminal prosecution against the trust for its unsafe care will finally be the jolt they need to prioritise patient safety and result in meaningful change.”
Mr Donoghue outlined multiple “serious” and “sustained” failings in the care of Mrs Andrews, exacerbated by staff shortages which led to the midwife caring for her also having to care for a patient on another ward.
Mrs Andrews was admitted to hospital on September 14, her planned due date, after an “uncomplicated” pregnancy.
An induced labour planned for September 7 was cancelled following a request by Mrs Andrews, but an investigation later found this was signed off by a midwife without consulting an obstetrician, and limited reasoning was given for the decision in medical notes.
Once Mrs Andrews was in labour, Wynter’s heartbeat was described as “suspicious” by doctors, with a decision made at 1.33pm on September 15 to deliver her via caesarean section.
These failures collectively led to a situation where Sarah Andrews and Wynter Andrews were exposed to a significant risk of avoidable harm.— Ryan Donoghue
Following complications during the surgery, she was delivered at 2.05pm in a “poor” condition and later died.
Mr Donoghue told the court that the trust “failed to ensure that staff were appropriately aware and trained” in policies concerning the care of expectant mothers and delivering babies, including physical checks, when to consult more senior colleagues and the prescription of drugs.
The CQC, which monitors and inspects health services in England, said last July it would be prosecuting the trust.
Bernard Thorogood, mitigating, told the court that the trust had made full and frank admissions over the failings from the outset of the investigation into the case by the CQC and the Healthcare Safety Investigation Branch.
Mr Thorogood added “the trust’s heart was in the right place” and that the trust is responsible for around 8,000 births a year, which often pass without incident, and that staff shortages were not unique to the trust.
He said: “Training, we accept, was not always what it should have been.
“There were guidelines and well-motivated, well-trained staff, not always as well-trained as they should have been and not always sufficient in number at this time, but those are the makings of a system that could work very safely.
“It didn’t here, and that is a sadness beyond any words I can express.
“But it could work safely, and it had worked safely.”
The maternity unit at the QMC was rated as inadequate by the CQC, with the hospital overall rated as requiring improvement, when the site was inspected last March.
Following the hearing, Anthony May, the trust’s chief executive, 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.”
District Judge Grace Leong told the court that she would pass sentence – which at most could be an unlimited fine – at 10am on Friday.
