Nottingham NHS trust fined £1.6m after deaths of three newborn babies

An NHS trust has been fined £1.6m after admitting it failed to provide safe care and treatment to three babies who died within months of one another. It is the first time a trust has been prosecuted more than once for maternity failures.

Nottingham university hospitals NHS trust (NUH) pleaded guilty to six counts in relation to the deaths of Adele O’Sullivan, Kahlani Rawson and Quinn Parker, who all died shortly after being born, and the treatment of their mothers.

The fine imposed on the trust was reduced from £5.5m, taking into account its financial position and guilty pleas but it was also told to cover prosecution costs of £67,755.23 and ordered to pay a £190 surcharge.

District judge, Grace Leong, said there were similarities among the "catalogue of failures" across the cases, in which all the mothers suffered a placental abruption, a serious condition in which the placenta starts to detach from the wall of the womb.

Those failures, the court heard, included staff being inadequately trained or equipped to interpret cardiotocography (CTG) results, used to monitor foetal heart rate and mothers' contractions, a failure to expedite delivery of babies, failure to recognise serious conditions and a handover process that was not up to standard.

The judge told the hearing, attended by NUH chief executive Anthony May, that the failures were "avoidable and should never have happened."

The judge added that the babies families: "Placed their trust in a system meant to protect expectant mothers and keep babies safe and that trust was broken.

"Three and a half years have gone by, yet for the families no doubt their grief remains as raw as ever and a constant presence in their lives that is woven into every moment. It is very difficult, if not impossible, to move on from the failures of the trust and its maternity unit. The weight of what should have been done different will linger indefinitely."

NUH, is first trust to be prosecuted by health and care regulator, the Care Quality Commission (CQC), more than once.  It is also the subject of the biggest ever inquiry into maternity services, covering 2,500 cases, since the NHS was founded.

The trust was fined £800k two years ago for failures in the care of Wynter Andrews, who died 23 minutes after being born at Queen’s Medical Centre, Nottingham, in September 2019.

In the latest sentencing, Nottingham magistrates court heard that “serious and systemic failures” exposed all three mothers and their babies to significant risk of avoidable harm.

The court heard that Adele O’Sullivan was born on 7 April 2021 at 29 weeks after an emergency caesarean at Nottingham’s City hospital after her mother, Daniela, a high-risk patient, noticed bleeding and developed abdominal pain.

She was not examined for eight hours before Adele was born, and said she was left “screaming in pain” with no painkillers, despite having a high-risk pregnancy.

Adele was born in “poor condition” and lived for only 26 minutes. A postmortem found she died as a result of severe intrapartum hypoxia, a condition caused by a lack of oxygen to the baby during labour and delivery.

Daniella O’Sullivan said in a victim impact statement:“People who were supposed to help me did not help but harmed me mentally and physically for ever. 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.”

Kahlani Rawson died on 15 June 2021 aged only four days from hypoxic ischemic encephalopathy, a brain injury that occurs when a baby’s brain doesn’t receive enough oxygen or blood flow.

His mother, Ellise Rawson, reported to the hospital with abdominal pain and reduced foetal movements but there was a delay in performing an emergency caesarean section.

Kahlani’s grandmother, Amy Rawson, told the court her grandson’s death was a “preventable tragedy” that left the family “devastated, broken and numb.”