Nottingham University Hospital NHS Trust has apologised, through its lawyer, after pleading guilty to failing to provide safe care and treatment to new mum Sarah Andrews and her baby daughter, Wynter Andrews - who died just 23 minutes after birth at the Queen's Medical Centre. Two charges were pleaded guilty to on Wednesday morning, January 25, on the Trust's behalf at Nottingham Magistrates' Court concerning its "failure to provide safe care and treatment".
The two charges, the first prosecution ever for the Trust, which is a care provider to 7 million in the East Midlands, concerned hospital service users Sarah Andrews - Wynter's mother, and baby Wynter herself. Bernard Thorogood, the Trust's barrister, said: "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.
"No words of mine and the Trust's can possibly be enough to pour sufficient oil on these difficult emotions for Mr and Mrs Andrews (who attended the hearing) and the family must be feeling. Quite a lot of what I have got to say will seem divorced from the terrible, deeply distressing events which have brought us here".
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The court heard about a report compiled by Miles Taylor, an expert consultant obstetrics and gynecologist, who made a number of criticisms of the care provider from the point of week 40 of Mrs Andrews' pregnancy onwards. There were various similar concerns from the Healthcare Safety Investigation Branch.
Points heard:
- Mrs Andrews spoke to a community midwife at 38 weeks and 3 days. She stated she did not wish to go ahead with an induction of labour. There was no evidence of the change in plan discussed with the obstetrics team
- Mrs Andrews stated she was unhappy to return home at 39 weeks and 3 days. The report author identified again she should have been referred for obstetrics opinion
- At 40 weeks she was admitted to the midwifery centre. Mr Taylor said Mrs Andrews' blood reading should have been interpreted as mild hypertension and ought to have led to obstetrics review
Cardiography findings ought to have triggered emergency C-section and delivery within minuutes - the delivery was at 2.05, almost three hours from a 11.10am pathological point
Mr Thoroughgood acknowledged the Trust's failings were serious but stressed the Trust is staffed and led by people who only want to do the best it can for its service users. He said it was the "first prosecution ever" and "first appearance in court ever" - which was a recognised feature of mitigation.
"Was this something to do with cost-cutting or trying to save money?" he said in addressing District Judge Grace Leong. "It very clearly was not, no one makes that observation," he added. A long-term national and local receruitment drive is underway, and the number of midwives leaving the profession is a "matter of national note," said Mr Thoroughgood.
"The Trust has reacted to fund the maternity unit to have a very large numbers of midwives. The unit's needs is less than it can be funded for. The Trust has created funding for more midwives, if it needs the funds".
The Trust will be sentenced on Friday (January 27) and the penalty is expected to be a fine.
The inquest into Wynter's death had heard how Nottingham University Hospitals Trust's neglect in care contributed to the death of baby Wynter, who was pronounced dead just 23 minutes after being born on September 15, 2019. Wynter's mother Sarah Andrews, a council worker who now lives in Mansfield, had said she felt "desperate, forgotten about and abandoned" after being admitted to the hospital the day before.
An inquest at Nottingham Coroner's Court had also heard staff failed to recognise Ms Andrews was in established and not latent labour, failed to act on high blood pressure readings and carried out four "inaccurate and insufficient handovers" to colleagues as part of a catalogue of errors in the lead up to baby Wynter's death. Midwives at the Queen's Medical Centre told the inquest they were "overworked and understaffed" and said they didn't feel able to professionally challenge colleagues at the hospital.
It comes after a string of failings involving the NUH maternity services. Nottingham families affected by maternity failings say they have been given hope after meeting the midwife in charge of a new review. Donna Ockenden met with parents, some of whom had babies who died or suffered serious injuries, in the city on Monday, July 11. NUH's scandal-hit maternity services at Queen's Medical Centre and City Hospital are rated 'inadequate' by health watchdog the Care Quality Commission (CQC).
Ms Ockenden, who uncovered 200 avoidable baby deaths at Shrewsbury and Telford NHS Trust across two decades, 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.
A heavily-criticised initial thematic review was scrapped midway through. The CQC can prosecute for a breach of this regulation or a breach of part of the regulation if a failure to meet the regulation results in avoidable harm to a person using the service or if a person using the service is exposed to significant risk of harm.
Acting Chief Executive of Nottingham University Hospitals at the time, Rupert Egginton, had said: “We are deeply sorry that we failed this family, and apologise unreservedly for the mistakes we made at the time. We have taken action to address the failings that led to this tragic loss and introduced a range of improvements designed to offer the best maternity care to families using our services.
“But we know there is a lot more work to do, and are committed to supporting the work of Donna Ockenden’s review team, which alongside the work of our own improvement team, will ensure we do everything necessary to learn and improve.”
The charges in full
The charges are: A registered person fail to provide care and treatment in safe way resulting in harm or loss. On 15/09/2019 at Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, were the service provider in respect of a regulated activity, namely Maternity and midwifery services, where care and treatment was not provided in a safe way for service users in that failed to discharge a duty imposed on it by Regulation 12(1) of the 2014 Regulations in that Nottingham University Hospitals NHS Trust, failed to provide safe care and treatment resulting in a service user, namely Sarah Andrews, (Wynter's mum) being exposed to a significant risk of avoidable harm occurring.
Contrary to regulations 12, 22(2) and 23(4) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Charge 2: A registered person fail to provide care and treatment in safe way resulting in harm or loss. On 15/09/2019 at Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB were the service provider in respect of a regulated activity, namely maternity and midwifery services, where care and treatment was not provided in a safe way for service users in that failed to discharge a duty imposed on it by Regulation 12(1) of the 2014 Regulations in that Nottingham University Hospitals NHS Trust failed to provide safe care and treatment resulting in a service user, namely Wynter Andrews, being exposed to a significant risk of avoidable harm occurring.
Contrary to regulations 12, 22(2) and 23(4) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
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