30 Jun 2021

Revealed: Over 30 deaths in Nottingham maternity units scandal

Health and Social Care Editor

Dozens of babies have died or been left with brain damage at a maternity service accused of bad care and neglect, a joint investigation by Channel 4 News and The Independent has found.

From 2010 to 2020, at least 46 babies have suffered brain damage and 19 have been stillborn at Nottingham University Hospitals (NUH) NHS trust maternity units.

There have also been 15 deaths at the units involving mothers and babies.

Sarah Hawkins’ daughter Harriet was stillborn in 2016 at one of the trust’s hospitals and she is calling for an independent inquiry.

She told this programme: “We were banging on the door saying ‘something’s wrong, babies are dying, and they shouldn’t’, and they didn’t listen, and they haven’t listened.”

NUH’s chief executive Tracy Taylor has apologised to the bereaved families and said that improving maternity services was a “top priority” for the trust.

‘It’s been horrific’

Ms Hawkins was a senior physiotherapist for NUH when she gave birth to Harriet. The baby died before she could take her first breath.

Ms Hawkins spent five days in labour which she says should have been a sign to staff that there was an issue, but it wasn’t recognised.

She was given an inappropriate and high dose of pain relief drug diamorphine and there was a delay in monitoring the foetal heart and information was not recorded or passed on correctly, an investigation into the death found.

“I trusted them. They didn’t listen to me,” she said: “It’s been horrific. It’s so exhausting.

“The trust haven’t been open or honest.”

She added: “I’d love the trust to have this guilt [that I feel]. Other babies have died since Harriet and we are the ones here trying to improve things. I wish they would accept that.”

It took NUH 159 days to declare a serious untoward incident (SUI) investigation and then an external review was commissioned into Harriet’s case.

A NUH spokesperson said the trust has “recognised on a number of occasions” that there were “deficiencies” in the Hawkins’ care and they are “committed to learning from that and improving”.

Poor record keeping

Channel 4 News and The Independent have found evidence of poor care of both mothers and babies and of repeated failures to investigate deaths of babies in NUH’s maternity units in the Queen’s Medical Centre and Nottingham City Hospital.

We also found failures to refer deaths to the coroner and poor record-keeping.

Data from NHS Resolution, a government arbitration and compensation body, shows 201 claims were made against the trust between 2010 and 2020 of which 84 have been finally settled.

From 2011 to 12, there were six claims where just under £14.5million was paid out, the data said.

According to NHS Resolution, last year, there were 14 claims which are still being settled. More than £91 million has been out paid in the past decade.

The trust faced accusations of a “failure or delay to treatment” in 25 incidents and on 13 occasions there were accusations of a “failure to recognise complications” as well as 10 inadequate nursing care cases.

‘Culture of fear’

Wynter Andrews was born and died on September 15, 2019 and an inquest found “gross failings” contributed to her death.

The inquest also heard the maternity unit at the Queen’s Medical Centre operated in a “fundamentally unsafe manner” and it was understaffed on the day she died.

A former senior midwife at NUH has spoken out against the way the maternity units were run.

Sue Brydon said the Nottingham City Hospital maternity unit operated under a “culture of fear”, adding that managers in the units were a “Teflon team” who failed to listen to concerns on staffing.

She said vacancies were allowed to build up which meant staff were stretched and a lack of beds meant at-risk women would face delays for treatment.

However, she also praised many of the staff for working hard to maintain safety.

‘Warning notice’

Last October, the Care Quality Commission (CQC) inspected the trust’s maternity services and “several serious concerns were identified”.

The health watchdog found poor risk management, which they said threatened mothers’ and babies’ safety.

The units were given an “inadequate” rating and the trust was served with a “warning notice”.

In May this year, CQC inspectors returned and found some improvements had been made but they said it still has some areas to address to ensure it comprehensively manages all risks to people’s safety.

‘We apologise’

Tracy Taylor, the Chief Executive of Nottingham University Hospitals, said: “We apologise from the bottom of our hearts to the families who have not received the high level of care they need and deserve, we recognise the effects have been devastating.

“Improving maternity services is a top priority and we are making significant changes including hiring and training more midwives and introducing digital maternity records.

“We will continue to listen to women and families, whether they have received excellent care or where care has fallen short; it is their experiences that will help us to learn and improve our services.”

Reporting: Victoria Macdonald and Shaun Lintern of The Independent

Producer: Toby Bakare

Camera operator: James Betteridge

Words: Calum Fraser