Nottingham: The story behind the biggest NHS maternity review – BBC News

The maternity units at Nottingham’s two main NHS hospitals are some of the most troubled and controversial in the UK.

Hundreds of babies died or were injured under the care of Nottingham University Hospitals (NUH) NHS Trust, which runs departments at City Hospital and Queen’s Medical Centre.

The units, which have been rated inadequate, are currently the focus of the biggest inquiry of its kind in NHS history.

The NHS has already paid out more than £100m between 2006 and 2023 for failings at these centres.

One of the first families to sound the alarm was Jack and Sarah Hawkins, whose daughter Harriet died in the womb at City Hospital in April 2016.

Dr and Mrs Hawkins, who worked for the trust, did not accept a hospital review which found “clear wrongdoing” and claimed their baby had died of an infection.

The couple pushed for an external review, which began four months later.

Published in January 2018, it found 13 failures and concluded the death was “almost certainly preventable”.

In the same year, midwives at the trust drafted a letter which later formed part of an inquest into the death of another baby, Winter Andrews.

She died 23 minutes after giving birth by caesarean section in September 2019.

At an inquest the following year, assistant coroner Lorinda Bower told Winter’s parents, Sarah and Gary, that her death was “clear and obvious neglect”.

Ms Bower cited the 2018 letter, from midwives on the unit to NUH bosses, which cited concerns about staffing levels as “the cause of a potential disaster”.

In December 2020, two months after Winter’s inspection, the care quality commission (CQC), the healthcare watchdog, rated the trust’s maternity services as inadequate.

Some staff had not completed training in key skills and “didn’t always understand how to keep women and babies safe,” the report said.

The inspectors added that there was “limited evidence that managers are monitoring the effectiveness of care and treatment and improving driving”.

This led to calls for a public inquiry into both the Andrews and Hawkins families.

Calls increased in July 2021 when Channel 4 News and The Independent reported that 46 babies in the trust had suffered brain damage and 19 had died between 2010 and 2020.

Plans for a review led by the local clinical commission (CCG) and NHS England were announced that month, with a view to reporting back by November 2022.

By March 2022, it had contacted almost 400 families but had already been criticized by campaigners for what they saw as independence, lack of experience and “moving with the viscosity of treacle”.

It was at this point that the family asked Donna Ockenden to undertake a full independent review.

Ms Ockenden has recently completed the investigation into what is the UK’s biggest maternity scandal at Shrewsbury and Telford NHS Trust.

Her appointment was confirmed in July 2022, and a review of care provided by the trust was launched in September of the same year.

Dr Hawkins said at the time: “We have made repeated inquiries and the same issues keep coming up.

“There is a fundamental problem in maternity services in this country.

“We have to understand that. It feels like right now you can do horrible harm to someone’s family and it doesn’t really register, and that’s okay.”

It was revealed in February that £101 million in compensation and legal fees had been paid out over the failure of maternity.

The payments related to 134 cases, with one family, whose son has cerebral palsy, fighting for a 10-year initial £6m package and then annual payments.

The NHS has paid for 22 cerebral palsy patients at NUH, paying £53.1 million in legal fees and damages over the past 17 years.

Stillbirths were the second highest at £4.6m, followed by successful claims for bowel damage (£3.4m), bladder damage (£2.2m) and fatality (£1.9m).

Dr and Ms Hawkins received £2.8 million – five years after Harriet’s death, the biggest stillbirth clinical negligence settlement in NHS history.

NUH was also fined £800,000 by magistrates in January 2023 after admitting failings over the death of Wynter Andrews – the biggest ever handed down to an NHS trust over maternity care.

In May this year, the scope of the review was widened from screening stillbirths, newborn deaths, injured babies and mothers and maternal deaths to prenatal care – all the links mothers have with maternity services until their babies are born.

The review team is now looking at cases from around 2,000 families and a final report is not expected until September 2025.

After attending an all-party parliamentary group on birth trauma in May, Ms Ockendon said: “I have listened to some of the accounts from around the country and they are absolutely shocking.

“Quite frankly, it’s impossible to have record after record with warm words saying things are getting better, and we have to do better.”

Trust bosses have repeatedly apologized for the failings, with chief executive Anthony May saying it was “transparent and fully engaged” and committed to improving “staffing levels, training and compliance with guidelines” within the department.

However, concerns remain.

Ms Ockenden told the BBC earlier this month that improvements had “stalled” and that the trust needed to “get back on track” after an unexpected inspection by the CQC in June.

In response, Mr May said the trust would “respond to the concerns identified by both Donna and the CQC”.

“I am confident that our maternity services are properly staffed and we have effective monitoring systems in place,” he said. “At the same time, I am committed to ensuring that we have adequate resources to maintain safe and effective care.”