NHS trust admits failing to provide safe care to babies who died after birth
An NHS trust has admitted it failed to provide safe care and treatment to three babies who died within months of each and their mothers as it is prosecuted for maternity failures for the second time.
Nottingham University Hospitals (NUH) NHS trust entered guilty pleas on Monday to six counts in relation to the deaths of Adele O’Sullivan, who was 26 minutes old when she died on April 7 2021, four-day-old Kahlani Rawson, who died on June 15 2021 and Quinn Parker, who was one day old when he died on July 16 2021 – and the treatment of each of their mothers.
NUH, which is currently at the centre of the largest maternity inquiry in the history of the NHS, is the first trust to be prosecuted by healthcare watchdog the Care Quality Commission (CQC) more than once after it was earlier fined £800,000 in 2023 for failures in the care of Wynter Andrews, who died 23 minutes after being born at the Queen’s Medical Centre (pictured) in Nottingham in September 2019.
On Monday, Nottingham Magistrates’ Court was told that “serious and systemic failures” exposed all three mothers and their babies to significant risk of avoidable harm.
The CQC says the trust did not ensure safe care and treatment due to a lack of adequate systems and processes being in place or not being appropriately implemented to ensure staff managed all risks to mothers and babies’ health and wellbeing.
The court heard Adele O’Sullivan was born following an emergency Caesarean at 29 weeks at Nottingham City Hospital after mother Daniela, a high-risk patient, noticed bleeding and suffered abdominal pain.
Despite this, vaginal examinations were not performed, delaying recognition that Mrs O’Sullivan was in labour and delaying the diagnosis of her bleeding.
Adele was born in “poor condition” and a decision was made to withdraw care, with a post-mortem finding she died as a result of severe intrapartum hypoxia.
In a victim impact statement read to the court, Mrs O’Sullivan said she was left “screaming in pain” with no painkillers and despite having a high-risk pregnancy, was not examined for eight hours before Adele was born.
She said: “People who were supposed to help me did not help but harmed me mentally and physically forever.
“We lost our beautiful daughter. Instead of bringing her home I had to leave the labour suite empty handed in a lot of physical and mental pain.
“We will forever be thinking about her and our family will never be complete.”
The court also heard Ellise Rawson reported to the hospital with abdominal pain and reduced foetal movements, but there was a delay in performing an emergency Caesarean section and her son Kahlani died of hypoxic ischemic encephalopathy after four days.
Kahlani’s grandmother Amy Rawson told the court on Monday that her grandson’s death was a “preventable tragedy” that left the family “devastated, broken and numb”.
The court was also told Emmie Studencki went to hospital four times before her son Quinn was born after suffering bleeding.
On the final occasion before Quinn was born, Ms Studencki called an ambulance at around 6.15am on July 14 2021 with paramedics estimating she had lost around 1.2 litres of blood both at home and in the ambulance on the way to City Hospital.
Despite this, the paramedics’ observations did not “find its way into the hospital’s notes”, with staff only recording a 200ml blood loss.
Quinn was “pale and floppy” when he was born via emergency Caesarean section that evening, and despite several blood transfusions, he was pronounced deceased after suffering multiple organ failure and lack of oxygen to the brain.
An inquest into Quinn’s death concluded it was a “possibility” he would have survived had a Caesarean section been carried out earlier.
In a statement, Ms Studencki said the trust’s treatment of her, her son and her partner Ryan Parker had been “contemptuous and inhumane” and they had been left broken.
She said: “We had an expectation of dignity and respect. We expected to be treated as humans.
“We as a family have been left behind, stranded in our grief. We are still chasing the full truth and accountability.”
Counsel acting on behalf of the trust told the families in court they offered their “profound apologies and regrets” to those affected and that improvements have been made, including hiring more midwives and providing further training to staff.
The hearing continues, and the trust is expected to be sentenced on Wednesday.
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