The story behind the largest NHS maternity review
BBC
Sarah and Jack Hawkins have continually called for a national inquiry into maternity services
The maternity units at Nottingham’s two major NHS hospitals are among the most troubled and controversial in the UK.
Hundreds of babies have died or been injured while under the care of Nottingham University Hospitals (NUH) NHS Trust, which runs the departments at City Hospital and the Queen’s Medical Centre.
The units, which have been rated inadequate, are currently the focus of the largest inquiry of its kind in NHS history.
The NHS has already paid out more than £100m over failings at these centres between 2006 and 2023.
One of the first families to raise the alarm was Jack and Sarah Hawkins, whose daughter Harriet died in the womb at City Hospital in April 2016.
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Nottingham City Hospital is one of two main sites run by NUH
Dr and Ms Hawkins, who both worked for the trust, did not accept a hospital review that found “no obvious fault” and stated their child had died of an infection.
The couple pushed for an external review, which began four months later.
Published in January 2018, it found 13 failings and concluded the death had been “almost certainly preventable”.
In the same year, midwives at the trust drafted a letter that would later form part of an inquest into the death of another baby, Wynter Andrews.
She died 23 minutes after being delivered by Caesarean section in September 2019.
At the inquest the next year, assistant coroner Laurinda Bower told Wynter’s parents, Sarah and Gary, that her death had been “a clear and obvious case of neglect”.
Ms Bower cited the 2018 letter, from midwives on the unit to NUH bosses, which had outlined concerns over staffing levels as “the cause of a potential disaster”.
In December 2020, two months after Wynter’s inquest, the trust’s maternity services were rated as inadequate by the healthcare watchdog, the Care Quality Commission (CQC).
The report found some staff had not completed training in key skills and “did not always understand how to keep women and babies safe”.
Inspectors added there was “limited evidence of managers monitoring the effectiveness of care and treatment and driving improvement”.
Andrews family
Wynter Andrews with her parents
This prompted both the Andrews and Hawkins families to call for a public inquiry.
Calls increased in July 2021, when Channel 4 News and the Independent reported that 46 babies suffered brain damage and 19 were stillborn at the trust between 2010 and 2020.
Plans for a review, led by the local clinical commissioning group (CCG) and NHS England, were announced that month and with the intention of reporting back by November 2022.
By March 2022, it had been in contact with nearly 400 families but it had already been criticised by campaigners for what they saw as a lack of independence, experience and “moving with the viscosity of treacle“.
Senior midwife Donna Ockenden is now leading the review
It was at this point that families called for Donna Ockenden to take charge of a fully independent review.
Ms Ockenden had recently completed the inquiry into what was, at the time, the UK’s biggest maternity scandal, at Shrewsbury and Telford NHS Trust.
Her appointment was confirmed in July 2022, with the review of care provided by the trust being launched in September the same year.
By July 2023, the review had become the UK’s largest, with the cases of 1,700 families to be examined.
Families gathered earlier this year to discuss their experiences
In September that year, Nottinghamshire Police launched its own inquiry into the failings.
Days later, the CQC announced that the maternity units had been upgraded from inadequate to requires improvement.
The next month, some of the families joined in calls for a national maternity inquiry.
At the time, Dr Hawkins said: “We have had repeated inquiries and it’s the same issues that keep on coming up.
“There is a fundamental problem with maternity services in this country.
“We need to understand it. At the moment it feels like you can cause horrific damage to someone’s family and it doesn’t really register, it doesn’t matter.”
Earlier this year, it was revealed the trust had paid out more than £100m in compensation and legal fees
The £101m in compensation and legal fees paid out due to maternity failings was revealed in February.
The payments related to 134 cases, with one family, whose son was left with cerebral palsy, fighting a 10-year battle for a package of an initial £6m and annual payments thereafter.
The NHS has paid out for 22 cerebral palsy cases at NUH, amounting to £53.1m in legal fees and damages in the last 17 years.
Stillbirth was the second highest figure at £4.6m, followed by successful claims of bowel damage (£3.4m), bladder damage (£2.2m) and fatality (£1.9m).
Dr and Ms Hawkins received £2.8m – the largest compensation settlement in a stillbirth clinical negligence claim in NHS history, five years after the death of Harriet.
NUH was also given a fine of £800,000 – the largest handed out to an NHS trust over maternity care – by magistrates in January 2023 after admitting failings over the death of Wynter Andrews.
PA
Sarah and Gary Andrews at Nottingham Magistrates’ Court
In May this year, the scope of the review was expanded from examining stillbirths, neonatal deaths, injured babies and mothers and maternal deaths, to antenatal care – all contact mothers have with maternity services until their children are born.
The review team is now looking into the cases of about 2,000 families and a final report is not expected until September 2025.
Speaking after attending an all-party parliamentary group on birth trauma in May, Ms Ockenden said: “I listened to some of the accounts from across the country and they were harrowing in the extreme.
“Quite frankly, we can’t keep having report after report with warm words saying things are going to get better, we have to do better.”
‘Issues identified’
Bosses at the trust have repeatedly apologised for failings, with chief executive Anthony May saying it was committed to “transparent and full engagement” and improvements on “staffing levels, training and compliance with guidelines” within the department.
Concerns, however, remain.
Ms Ockenden told the BBC earlier this month that improvements had “stalled”, saying the trust needed to “get back on track” following an unannounced inspection by the CQC in June.
In response, Mr May said the trust would “respond to the issues identified by both Donna and the CQC”.
“I am confident that our maternity services are properly staffed and that we have effective monitoring systems in place,” he said. “At the same time, I am committed to ensuring we have sufficient resources in place to maintain safe and effective care.”
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