NHS trust fined £1.6m for ‘catalogue of failures’ that led to deaths of babies

An NHS trust has been fined £1.6 million for “avoidable failings” that led to the deaths of three babies in 2021.

Nottingham University Hospitals (NUH) NHS Trust pleaded guilty at Nottingham Magistrates’ Court on Monday to six counts of failing to provide safe care and treatment in relation to the deaths of Adele O’Sullivan, who was 26 minutes old when she died on April 7 2021, Kahlani Rawson, who died aged four days old on June 15 2021, and Quinn Parker, who was one day old when he died on July 16 2021 – and each of their mothers.

The court was told that “serious and systemic failures” exposed all three mothers, Daniela O’Sullivan, Ellise Rawson and Emmie Studencki, and their babies to significant risk of harm.

District Judge Grace Leong told the hearing, which was attended by NUH 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 District Judge Leong expressed her “deepest sympathy” to each of them and said the trust they put in NUH to deliver their babies safely had been broken.

She said: “Daniela and Adam O’Sullivan, Ellise Rawson and her grandmother Amy, and Emmie Studencki and Ryan Parker placed their trust in the system that was supposed to protect expectant mothers and keep babies safe, and that trust was broken.

“The death of a child is a tragedy beyond words, and where that loss is avoidable the pain is even more profound.

“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 different will linger indefinitely.”

District Judge Leong highlighted “critical failures” in care as she said the purpose of the sentencing hearing, in which she was limited to imposing a fine, was to “ensure the trust responsible is held to account and meaningful steps are taken to prevent such failures in the care of mothers and their babies, while recognising the harm caused”.

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 in Nottingham in September 2019.

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.

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 £612 million, 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 £100 million.

She said: “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 £1.6 million fine was broken down into £700,000 for the death of Quinn Parker, £300,000 each for the deaths of Adele O’Sullivan and Kahlani Rawson and £100,000 each for the mothers.

The trust was also ordered to pay prosecution costs of more than £67,000 as well as a surcharge of £190.

The court heard on Monday that 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.

The trust admitted there was a failure to deliver Adele in a timely manner once Mrs O’Sullivan had been transferred to the delivery suite and that hospital staff did not communicate properly during the handover.

There was also a lack of appropriate escalation of care and cardiotocography (CTG) monitoring – a continuous recording of the fetal heart rate via an ultrasound.

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.

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.”

The court also heard Ellise Rawson reported to the hospital at 37 weeks 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.

The court heard a decision to deliver Kahlani should have taken place earlier due to the abnormal fetal heart rate pattern and there was a failure to assess the risks to the health and safety of mother and baby when she presented with what was clearly a placenta abruption.

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.

On Monday, counsel acting on behalf of the trust offered their “profound apologies and regrets” to those affected and said that improvements have been made, including hiring more midwives and providing further training to staff.

In a statement released after the hearing, NUH Chief Executive Anthony 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.

“These families have shown incredible strength during this time, and I can only imagine how painful it must have been for them to share their experiences again. Listening to them in court was moving and provided further incentive for us to continue to improve our services.

“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.

“The Trust recognises the concerns raised by the CQC and has acted upon them to improve the services we provide to women and families in our care. The changes that we have made mean that we are working in a different environment than 2021 and we believe that we now have a safer and more effective maternity service.

“This was reflected in the CQC report published in September 2023, where the overall rating for our maternity services was improved.

“The CQC recognised that CTG monitoring for women, which was highlighted as an area of concern in these cases, was now completed appropriately and was documented in line with national guidance.”

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.”