The first prosecution of Nottingham's hospital Trust for its care of mum-to-be Sarah Andrews and her daughter who died will finally be the "jolt they need to prioritise patient safety and result in meaningful change". Speaking outside court, after the Care Quality Commission case was adjourned for sentencing on Friday (January 27), heartbroken Sarah Andrews spoke of her cherished daughter Wynter who died in her and her partner's arms at just 23 minutes of life.
Her powerful statement came after Nottingham University Hospital NHS Trust, which runs the Queen's Medical Centre, was prosecuted over "failure to provide safe care and treatment" of both Wynter and her mum, leading up to her birth by emergency C-Section at the QMC, and tragic death.
Sarah is bringing a separate civil case against the Trust, an action yet to be listed. Wynter's death is one of those looked at by respected and high profile health care leader in the UK and internationally Donna Ockenden - who uncovered 200 avoidable baby deaths at Shrewsbury and Telford NHS Trust across two decades, and who was hired in May to conduct a similar review in Nottingham. It came one month after more than 100 families wrote to former Health Secretary Sajid Javid.
The Trust's barrister, Bernard Thorogood pleaded guilty on its behalf to two charges brought by the CQC against the Trust - where it failed to provide safe care and treatment resulting in service users, Mrs Andrews and her daughter, being exposed to a significant risk of avoidable harm occurring. The penalty is expected to be a substantial fine for the Trust, whose budget is set by an external authority, and the Trust itself has been in deficit for years.
Read more: NUH speaks of 'deepest regret' as it admits failing to provide safe care to baby Wynter Andrews
Mrs Andrews said: "Our cherished daughter Wynter was born on the 15th September, 2019, who tragically died just 23 minutes after birth. As first-time parents all we ever wanted was to bring our precious baby home.
"After multiple investigations and the conclusions of the coroner revealed that we were failed in the most cruel way by a Trust board that has allowed the maternity services at the hospital to be fundamentally unsafe.
"Failures that were described in court today as serious and sustained. Management at the Trust were repeatedly warned by staff about the safety of 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 critical changes needed.
"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. We are mindful that the financial penalty to be imposed on the Trust does nothing to address the individual culpability.
"It remains the case that no medical professionals or managers have been professionally disciplined for their failures in care. The senior leaders of the Trust at the time of Wynter's death have conveniently moved on and have been able to pursue other high-paying roles in the NHS.
"They have not had to face up to their actions which cost our baby daughter her life. Until there is proper accountability and learning from mistakes, babies and mothers will continue to be harmed and families will continue to have their hearts broken.
"We thank the CQC for bringing this prosecution. We hope in the future that there will be close scrutiny by all regulators to ensure that history is not repeated. We also like to encourage anyone who feels that their maternity care fell short, to share their experience with the Independent review team led by Donna Ockenden, to add their voice to the ever-growing number of families affected by this maternity scandal."
Mr Thorogood told the hearing on Wednesday (January 25): Clearly the first thing that I must do on behalf of the Trust is to express its deepest regret and apology. To do so today is a reiteration of an apology made before".
“Today, we pleaded guilty and will accept, in full, the findings of the court"
Following the hearing, Chief Executive Anthony May 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.”
Since Wynter’s death, NUH 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
If women and families currently accessing maternity services at NUH have any concerns or questions about their care, please talk to your midwife or consultant.
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