An NHS trust has been fined £1.6m after admitting it failed to provide safe care and treatment to three babies who died within days of their births.
The Care Quality Commission (CQC) had charged Nottingham University Hospitals (NUH) NHS Trust over the deaths, which all occurred in 2021.
The trust pleaded guilty to six charges of failing to provide safe care and treatment to the three children and their mothers at Nottingham Magistrates’ Court on Monday.
The charges were in connection to the deaths of Adele O’Sullivan, who was 26 minutes old when she died on 7 April 2021, four-day-old Kahlani Rawson, who died on 15 June 2021, and Quinn Parker, who was one day old when he died on 16 July 2021.
District Judge Grace Leong told the hearing, which was attended by the trust’s chief executive since September 2022 Anthony May, that the “catalogue of failures” in the trust’s maternity unit were “avoidable and should never have happened”.
Family members cried in the courtroom as the judge expressed her “deepest sympathy” to each of them and said the trust they put in NUH to deliver their babies safely had been broken.
“The death of a child is a tragedy beyond words, and where that loss is avoidable the pain is even more profound,” she said.
“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.
“The grief of a baby is not just about the past, it is about the future that is stolen. It is a lifetime of missing first words, first steps, first days of school, missing memories that should have been made.
“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 differently will linger indefinitely.”
‘Systematic failures’
District Judge Leong highlighted concerns over a lack of escalation of care, an inadequate communications system and a failure to provide “clear and complete” information sharing.
She said: “I accept there were systems in place but there were so many procedures where guidance was not followed or adhered to.
“The failures in combination amounted to systematic failures in the provision of care and treatment.”
The trust has an average turnover of £612m, but District Judge Leong said she was “acutely aware” that all its funds as a publicly funded body were accounted for and that the trust is currently operating at a deficit of around £100m.
“I can’t ignore the negative impact this will have… but the significant financial penalty has to be fixed to mark the gravity of these offences and hold the trust to account for their failings,” the judge said.
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The £1.6m fine was broken down into £700,000 related to the death of Quinn Parker, £300,000 each for the deaths of Adele O’Sullivan and Kahlani Rawson, and three amounts of £100,000 related to the care provided to each of the mothers.
Lawyers acting on behalf of the trust told the families in court they offered their “profound apologies and regrets” and that improvements have been made, including hiring more midwives and providing further training to staff.
‘Contemptuous and inhumane’
The court was told that one of the pregnant women, Emmie Studencki, went to the hospital four times suffering bleeding before her son Quinn was born.
On the final occasion before Quinn was born, Ms Studencki called an ambulance at around 6.15am on 14 July 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 dead after suffering multiple organ failure and lack of oxygen to the brain.
An inquest 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”.
‘We lost our beautiful daughter’
Adele O’Sullivan died 26 minutes after being born following an emergency Caesarean at 29 weeks in April 2021, the court also heard.
Her mother Daniela had noticed bleeding and suffered abdominal pain but in a victim impact statement said she was left “screaming in pain” with no painkillers. Despite having a high-risk pregnancy, she was not examined for eight hours before Adele was born.
Adele was born in “poor condition” and a decision was made to withdraw care, with a post-mortem examination finding she died as a result of severe intrapartum hypoxia.
Daniela 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.”
The trust also admitted liability in another case involving mother Ellise Rawson, who had reported abdominal pain and reduced foetal movements. She was delayed in receiving an emergency Caesarean section in June 2021. Her son Kahlani suffered a brain injury and died four days later.
Kahlani’s grandmother Amy Rawson told the court that her grandson’s death was a “preventable tragedy” that had left the family “devastated, broken and numb”.
This case is the second time the CQC has prosecuted the trust over failures in maternity care.
It was fined £800,000 for a “catalogue of failings and errors” that led to the death of a baby 23 minutes after she was born at the Queen’s Medical Centre in Nottingham in September 2019.
NUH is also at the centre of the largest maternity inquiry in NHS history, with midwife Donna Ockenden leading the investigation.
In February she confirmed the number of families taking part has increased to 2,032 – forcing a delay to her report’s publication until June 2026.
‘We fully accept the findings’
In a statement released after the hearing, NUH chief executive, Mr May said: “The mothers and families of these babies have had to endure things that no family should after the care provided by our hospitals failed them, and for that I am truly sorry.
“Today’s judgment is against the trust, and I also apologise to staff who we let down when it came to providing the right environment and processes to enable them to do their jobs safely.
“We fully accept the findings in court today and have already implemented changes to help prevent incidences like this from this happening again.”
He added that a CQC report published in September 2023 showed there had been an improvement in the overall rating for the trust’s maternity services.
Helen Rawlings, CQC’s director of operations in the Midlands, said in a statement after the sentencing: “The care that these mothers received, and the death of these three babies is an absolute tragedy and my thoughts are with their families and all those grieving their loss under such sad circumstances.
“All mothers have a right to safe care and treatment when having a baby, so it’s unacceptable that their safety was not well managed by Nottingham University Hospitals NHS Trust.
“The vast majority of people receive good care when they attend hospital, but whenever a registered health care provider puts people in its care at risk of harm, we seek to take action to hold it to account and protect people.
“This is the second time we have prosecuted the trust for not providing safe care and treatment in its maternity services, and we will continue to monitor the trust closely to ensure they are making and embedding improvements so that women and babies receive the safe care they deserve.”
