The mother of a baby who died following multiple failures by hospital staff has said a record fine handed to the NHS trust responsible was a ‘clear message’ that patient safety must be prioritised.
Sarah Andrews’ first child, Wynter, died 23 minutes after being born on September 15 2019 due to lack of oxygen to the brain following an emergency caesarean section, something which an inquest found could have been prevented had staff at the Queen’s Medical Centre (QMC) in Nottingham acted sooner.
On Friday, the Nottingham University Hospitals (NUH) NHS Trust, which runs the QMC, was fined £800,000, the highest fine ever issued for failings in maternity care, after pleading guilty at Nottingham Magistrates’ Court on Wednesday to two charges relating to Wynter and Mrs Andrews of being a registered person who failed to provide care or treatment in a safe way resulting in harm or loss.
Mrs Andrews previously said she and her daughter were failed ‘in the most cruel way’ and in a statement on Friday added: ‘We thank the judge, and recognise the delicate balance that has to be made to impose this significant fine, which we hope sends a clear message to trust managers that they must hold patient safety in the highest regard.
Sarah and Gary Andrews are pictured outside Nottingham Magistrates’ Court after Nottingham University Hospital Trust was fined following the death of their baby, Wynter
Wynter Sophia Andrews died at Queen’s Medical Centre, Nottingham, on September 15 2019
‘Sadly, we are not the only family harmed by the trust’s failings.
‘We feel that this sentence isn’t just for Wynter, but for all the other babies that have gone before and after her.’
The fine represents only the second time a trust has been prosecuted for failings in maternity care, after East Kent Hospitals University NHS Foundation Trust was fined £733,000 following a baby’s death in June 2021.
It is also the first time the NUH trust has been criminally prosecuted for any offence.
As well as the fine, which will be paid within two years, the NUH trust must also pay £13,668.65 in prosecution costs and a £181 victim surcharge.
Ryan Donoghue, prosecuting on behalf of the Care Quality Commission (CQC), previously told the court that staff failed to follow the trust’s own guidelines on a number of issues.
Bernard Thorogood, mitigating, had said that the trust accepted that staff training was an issue but that staff shortages, highlighted as a key reason behind the incident, were a national problem and that maternity care was now fully funded.
Passing sentence – which could have been a maximum of an unlimited fine – District Judge Grace Leong said: ‘Ultimately the catalogue of failings and errors exposed Mrs Andrews and her baby to a significant risk of harm which was avoidable.
Mr and Mrs Andrews are pictured speaking to the press following the verdict on Friday
Ms Andrews had started having contractions and experiencing pain six days before being admitted to the maternity ward in Queen’s Medical Centre on September 14
‘Such errors ultimately resulted in the death of Wynter and post-traumatic stress for Mrs Andrews as well as 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.’
However, passing judgement on the fine, she added she was ‘acutely aware’ the trust was already operating in a deficit, stating that the negative impact of any fine on patient care must be considered.
The trust accepted wrongdoing to the CQC at the earliest stage of its investigation, and in a statement, its chief executive, Anthony May, said: ‘I am truly sorry for the pain and grief that we caused Mr and Mrs Andrews due to failings in the maternity care we provided.
‘These were serious failings that led to the worst possible outcome and we let them down at what should have been a joyous time in their lives.
‘I want to pay tribute to Mr and Mrs Andrews, who have shown incredible courage during this process despite the fact that it has brought additional pain and suffering.
Baby Wynter’s mother Sarah Andrews said she felt ‘humiliated, worthless and forgotten’ after arriving at the hospital
‘On Wednesday we pleaded guilty and accepted responsibility for the findings of the CQC and today we accept, in full, the sentence of the court.
‘While words will never be enough, I can assure our communities that staff across NUH are committed to providing good quality care every day and we are working hard to make the necessary improvements, including engaging fully and openly with Donna Ockenden and her team on their ongoing independent review into our maternity services.’
The trust also said that multiple improvements had been made following the incident, including improved digital systems for staff, greater investment in equipment, a strengthened senior clinical team, continued recruitment and retention of midwives and improvements to staff feedback services, among others.
The provision of maternity care across the trust is currently under review by Donna Ockenden, a senior midwife, following concerns raised by several families, with Wynter’s case forming part of the review.
A tragic inquest in 2020 found the infant died from hypoxic ischaemic encephalopathy – a loss of oxygen flow to the brain – 23 minutes and 30 seconds after being born.
This could have been prevented had staff at the QMC in Nottingham delivered her earlier.
The Care Quality Commission, which regulates health services in England, announced in July last year that it would prosecute the trust on two counts, one in relation to Wynter and another to her mother, Mrs Andrews.
Speaking at the inquest into Wynter’s death in 2020, Mrs Andrews said she felt ‘humiliated, worthless and forgotten’ after arriving at the hospital.
She had started having contractions and experiencing pain six days before being admitted to the maternity ward on September 14.
Jo Taylor, a midwife at King’s Mill Hospital who had conducted a home visit, made the call to midwife Clare Lee at the hospital on Sarah’s behalf, the court heard.
Ms Lee said she hadn’t taken into consideration that the contractions had started days prior.
This led to Ms Andrews being placed on a ward where she was only seen by midwives, and not clinicians.
A Healthcare Safety Investigation Branch report into Wynter’s death also found Ms Lee had failed to act on two high blood pressure readings.
These should have led to a medical examination for Ms Andrews.
To date, dozens of babies are believed to have died or been left with serious injuries as a result of care at the trust, which runs Nottingham’s City Hospital and Queen’s Medical Centre
Donna Ockenden is set to lead the investigation after some 100 mothers wrote to the then health secretary Sajid Javid to criticise the thematic review of maternity incidents at Nottingham University Hospitals
Ms Lee passed the care of Sarah over to Adele Kirk, a midwife who was working the night shift, and she was given diamorphine, which requires a doctor’s approval.
This was approved without Ms Kirk speaking or seeing the doctor herself, as she says she believed this had happened beforehand.
Diamorphine can slow down contractions and can cause the baby not to breathe properly.
Both midwives told the court they had made a mistake by believing Ms Andrews was in latent labour and not established labour.
The first stage of labour is broken down into to the latent phase and the established phase.
Latent labour is the initial part of the first stage of labour where there are irregular contractions.
Ms Andrews gave birth later that day on September 15 via a caesarean, but Wynter passed away shortly after being delivered.
Dozens of babies are believed to have died or been left with serious injuries due to poor care at the trust.
Donna Ockenden was appointed by ex-Health Secretary Sajid Javid to investigate the horrific stories at Nottingham University Hospitals
Ms Ockenden had previously chaired a damning review into two decades of appalling care at Shrewsbury and Telford Hospital NHS Trust.