A new investigation into the United Kingdom’s National Health Service reveals that dozens of babies died or were left with serious injuries after being born at several hospitals in Nottingham. These facilities have a shoddy record when it comes to caring for newborns and expecting mothers. The news is a wake-up call for providers and administrators, but nothing can make up for all the damage they’ve caused.
A History of “Inadequate” Care
The latest report shows that 46 babies in Nottingham suffered brain damage and another 19 were stillborn between 2010 and 2020, leading to £91m in damages and additional costs. The NHS trust Nottingham University Hospitals (NUH) oversees both Queen’s Medical Centre (QMC) and Nottingham City Hospital, where the deaths took place.
In addition to cases of brain damage and stillbirth, investigators found 15 other deaths that providers failed to investigate. They said, “Key medical notes were missing or never made, while others were completely inaccurate”.
In response to the report, Tracy Taylor, chief executive for the NUH trust, said, “We apologize from the bottom of our hearts to the families who have not received the high level of care they need and deserve, we recognize 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,” Taylor added.
This isn’t the first time these facilities have been flagged for providing substandard care. Just last year, inspectors with the Care Quality Commission (CQC) rated the maternity wards at both facilities as “inadequate” after two families came forward with their concerns.
A Case of Two Deaths
Wynter Andrews and Harriet Hawkins died at facilities in the trust in 2016 and 2019 respectively, and their families are still looking for answers. A coroner lambasted the care the infants received after inspecting their bodies. Inspectors found evidence of low staffing rates, poor leadership, and lack of training among providers.
Wynter Andrews was born in 2019 via c-section, but died shortly after. The inquest ruled Andrew’s death “a clear and obvious case of neglect.” Assistant Coroner Laurinda Bower said, “The early care of [Ms.] Andrews was littered with departures from local and national guidance which led to multiple missed opportunities to seek earlier medical care for baby Wynter.”
His mother, Sarah Andrews, was admitted to Queen’s Medical Center six days after starting contractions. The inquest found that the midwives told the patient the maternity ward was “busy” when she arrived, and that patient information wasn’t handed off between shifts.
The next morning, the doctor attending to Andrews failed to pick up on concerns raised by the midwives about a possible infection, which delayed her c-section.
Bower said, “repeated failures by all staff” to share notes was “perpetuated by incoming professionals who relied upon an inadequate and insufficient handover of the patient situation,” which led to risk factors “being omitted from their clinical decision making.”
The report goes on to say Wynter was born “in poor condition” at 14:05, with the umbilical cord “wrapped tightly around her leg and neck,” and efforts to resuscitate her were abandoned 23 minutes later.
“If [she] had been delivered earlier, it is likely that her death would have been avoided,” Bower added.
Mrs. Andrews welcomed the findings of the report, but said, “It is quite an upsetting read,” stating:
“We do feel the trust doesn’t really have the ability to change. They have had opportunities to change, and they made lots of promises but nothing has changed. We just want our daughter’s life to mean something. We don’t get to see them grow up and get married, all those things you expect as a parent.”
Bower said the maternity unit was so overwhelmed that nurses were caring for multiple infants in critical condition at the same time. Unfortunately, this meant that Andrews “was not afforded the care and attention that she clinically required.”
Harriet Hawkins was delivered stillborn at Nottingham City Hospital in 2016, nine hours after dying. A report cited 16 failures within the facility, leading investigators to believe Hawkins’ death was “almost certainly preventable.”
Both of her parents work for the country’s NHS and said, “Since Harriet’s death we have continuously tried to raise awareness, through multiple different bodies, that maternity services were unsafe at NUH.” They are glad the CQC investigated, but they said the results were no surprise. “We had an independent review which found 13 significant failings and years later the same things are happening.”
Solicitor Irwin Mitchell, who’s representing many of the families who have lost children at the trust, commented on the results of the latest inquest. “We welcome NUH’s pledge to ensure maternity services are improved but it’s now vital that decisive action is taken to improve services.”
“Patient safety should always be the fundamental priority. It’s also essential that families affected by issues in maternity care receive the help and support they require in order to establish answers to their concerns,” Mitchell added.
Clearly, the NHS could use more midwives and neonatal nurses. It’s a theme that will likely continue for years to come unless the government can find a way to recruit and retain more providers.