NUH truly sorry following deaths of three babies in 2021
The Trust believes that changes made mean it now has a safer and more effective maternity service.
The Chief Executive of Nottingham University Hospitals NHS Trust (NUH) has said he is truly sorry after the Trust was fined £1.6m following sentencing for the prosecutions of the deaths of three babies, Adele O’Sullivan, Kahlani Rawson and Quinn Parker in 2021.
NUH was fined at Nottingham Magistrates Court on Wednesday 12 February, after it pleaded guilty to charges brought by the Care Quality Commission (CQC). The charges were brought under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 for failure to provide safe maternity care and treatment resulting in a significant risk of avoidable harm and, in one case, actual avoidable harm, contrary to Regulations 12 (1) and 22 of the Act.
In addition to the fine, NUH must pay costs of £67,755.23.
The babies all died while being cared for by NUH maternity services. Three charges are in connection with the babies, and three others in connection with their mothers, Daniela O’Sullivan, Ellise Rawson and Emmie Studencki.
Following the hearing, 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 cardiotocography (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.”
Other improvements made within maternity services to help to prevent cases like these from occurring again, include:
- Increased fetal monitoring training and support in clinical areas, which has meant that the care provided for mothers and babies at NUH is now safer.
- Guidelines and protocols being updated and made more accessible and visible to staff, improving the recording of CTGs.
- Handover processes have been improved, with a more joined up approach across services using verbal and written updates and meetings to ensure that all staff, including consultants, can manage patient safety, reduce the likelihood of information being missed or misinterpreted, and to support with managing staffing levels throughout the day.
- Investment and training into the development and recruitment of maternity staff has seen a significant increase in staffing numbers on our wards and a positive reduction in the number of staff leaving the Trust. This translates to a safer maternity service for babies, mothers and our staff.
Anthony May joined the Trust as Chief Executive in September 2022 and has been committed to the Maternity improvement Programme since.
He said: “Too many women and families have been let down by our maternity services and when I joined the Trust, I committed to supporting our colleagues to improve them in an open and transparent way. I am in regular contact with the families who are part of the Independent Maternity Review, along with Donna Ockenden, and am grateful for the opportunity this gives us to improve.
“While we can see that improvements are happening, we know there is more to do and colleagues across the Trust are working hard every day to create the best environment and to provide the best care for babies, mothers and families in our hospitals. I can see that happening and I am thankful to our staff for being so committed to improving our services and we owe it to them to provide the right culture and environment to do that.
“Through our Maternity Improvement Programme, we have reintroduced our Home Birthing service, significantly increased staff numbers, feedback from patient surveys has improved and is consistently positive. We have also heavily invested in our services, launching a new Fetal Medicine Unit and Neonatal Unit. There is more to do, but we know we are on the right path to improvement.”