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In a rare criminal prosecution by the Care Quality Commission (CQC), earlier this year Nottingham University Hospitals NHS Trust (NUH) was ordered to pay a record breaking fine after admitting failings in the care of a baby who died minutes after birth.
Wynter Sophia Andrews died on 15 September 2019, 23 minutes after she was born by emergency caesarean at the Queen’s Medical Centre. She suffered a loss of oxygen to the brain following an infection and umbilical cord compression during labour. The inquest into her death concluded there was a “clear and obvious case of neglect” and “gross failings” led to her avoidable death. If she had been delivered earlier, its likely her death would have been prevented.
The subsequent CQC investigation found multiple failings and missed opportunities in the management of her mother, Sarah Andrew’s, pregnancy and in Wynter’s delivery, including:
- Inducing labour at 37+1 weeks for ‘insufficient and undocumented’ reasons
- Failing to acknowledge Sarah’s concerns about the induction of labour
- Missing signs of hypertension which should have prompted obstetric-led care and continuous monitoring of Wynter’s heart rate
- Administering diamorphine to Sarah without following proper processes
- Failing to deliver Wynter in time. Wynter’s CTG readings should have triggered an emergency caesarean section and delivery within 60 minutes. Wynter was not born for a further 30 minutes and died 23 minutes later.
The Trust pleaded guilty to two offences of failing to provide safe care and treatment to a mother and her baby. Sentencing NUH at Nottingham Magistrates Court, Judge Grace Leong said:
“The catalogue of failings and errors exposed Mrs Andrews and her baby to a significant risk of harm which was avoidable, and such errors ultimately resulted in the death of Wynter and post-traumatic stress for Mrs Andrews and Mr Andrews.”
“My assessment is that the level of culpability is high, where offences on Wynter and Mrs Andrews are concerned. There were systems in place, but there were so many procedures and practices where guidance was not followed or adhered to or implemented.”
Unfortunately, the judge’s comments could apply to many of our clients’ experiences. Whether due to staff shortages, workplace culture or general underinvestment in services, all too often national guidelines and procedures are not properly followed, leading to tragic outcomes for families.
In addition to the criminal conviction, the Trust is currently subject to an independent review of its maternity services, led by Donna Ockenden. Ockenden’s previous report into the Shrewsbury maternity failings made for shocking reading.
Significant concerns about NUH maternity services were raised following an investigation by the Independent and Channel 4 News. From 2010 to 2020, they found that 46 babies had suffered brain injury at birth, 19 babies had been stillborn and 15 had died.
Worryingly, at the national level, the CQC has also noted a deterioration in women’s maternity care experiences over the last five years. Many women report that they did not get the help they needed during labour and birth, and that they did not feel listened to when they raised concerns.
Following the judgment against NUH in January, Sarah and Gary Andrews spoke movingly outside the court:
“This sentence isn’t just for Wynter but it is for all the other babies that have gone before and after”
We hope that the criminal conviction will be a wake-up call for maternity services across the country, encouraging Trusts to listen to women and implement the lessons learned.
We must also recognise that criminal prosecutions of NHS Trusts are a very blunt tool by which to raise standards of care. Hospital managers must focus on resources, training issues and staffing levels, and ensure that they fully support maternity departments to avoid repeated errors of this nature.
FURTHER INFORMATION
If you would like any further information or advice about the topic discussed in this blog, please contact our Medical Negligence and Personal Injury team.
ABOUT THE AUTHORs
Chloe Jacot is a trainee solicitor at Kingsley Napley and is currently undertaking her first seat in the Medical Negligence and Personal Injury team. Chloe assists solicitors in litigating a variety of complex medical negligence cases, including birth and spinal injuries. She volunteers for the Action Against Medical Accidents helpline, advising individuals who have sustained an injury as a result of medical negligence.
We welcome views and opinions about the issues raised in this blog. Should you require specific advice in relation to personal circumstances, please use the form on the contact page.
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