In a letter to Mr Nichols and chief executive Neil Thwaite, which has been seen by the BBC, NHS England’s…
An NHS trust has been fined £800,000 after admitting failings in the care of a baby who died after 23 minutes.
Nottingham University Hospitals (NUH) pleaded guilty over the care of Wynter Andrews, who died after being born in 2019 at the Queen’s Medical Centre.
The fine is the largest handed out to an NHS trust over maternity care.
Nottingham Magistrates’ Court heard a “catalogue of failings” exposed Wynter and her mother Sarah to “a significant risk of harm”.
However, District Judge Grace Leong said she was “acutely aware” the fine would be paid for by funding that would usually be used for patient care.
The criminal prosecution is one of only two the Care Quality Commission (CQC) has brought against an NHS maternity unit.
Wynter died from hypoxic ischaemic encephalopathy – a loss of oxygen flow to the brain – which could have been prevented had staff delivered her earlier.
An inquest into her death, held in 2020, heard Sarah Andrews, 33, had been admitted to hospital on 14 September, six days after initially suffering contractions.
Nottingham Coroner’s Court heard the maternity unit was “busy” when Mrs Andrews arrived, with information on her patient history not handed over properly to other staff at shift changes.
After her arrival, Mrs Andrews was “misdiagnosed” as being in the latent phase of labour, when there were “clear clinical signs” she was in established labour, which meant she did not receive the level of care that she needed.
The inquest heard there were “missed opportunities” to move labour along and begin one-to-one care.
It also heard of missed chances to “provide additional monitoring” of the baby’s wellbeing, “and to have taken action if that monitoring had shown that baby Wynter was in distress”.
A doctor seeing her the following morning did not pick up on concerns raised by midwives about a possible infection or over a trace examination of Wynter, the inquest was told.
Wynter was delivered “in poor condition” at 14:05 on 15 September 2019, with the umbilical cord “wrapped tightly around her leg and neck”, and efforts to resuscitate her were abandoned 23 minutes later. She died in her parents’ arms.
The coroner, Laurinda Bower, said “systemic issues” contributed to the neglect of Wynter, adding the unit was so short staffed, midwives were looking after a number of high-risk patients simultaneously.
Before her conclusion was delivered, Ms Bower said she had received an anonymous letter from midwives on the unit – dated 10 months before Wynter’s death – addressed to bosses at the trust outlining concerns over staffing levels as “the cause of a potential disaster”.
Calling it a “clear and obvious case of neglect”, the coroner said: “If [Wynter] had been delivered earlier, it is likely that her death would have been avoided.”
‘Pain and grief’
Passing sentence on Friday, the district judge said: “The catalogue of failings and errors exposed Mrs Andrews and her baby to a significant risk of harm which was avoidable, and such errors ultimately resulted in the death of Wynter and post-traumatic stress for Mrs Andrews and Mr Andrews.”
In a statement, Wynter’s parents said the fine had “demonstrated the seriousness” of the trust’s failings.
They added: “These criminal proceedings are designed to act as a punishment and a deterrent. No financial penalty will ever bring Wynter back.
“We hope [the fine] sends a clear message to the trust managers that they must hold patient safety in the highest regard.
“Sadly, we are not the only family harmed by the trust’s failings. We feel that this sentence isn’t just for Wynter, but it’s for all the babies who have gone before and after her.”
On Wednesday, the trust pleaded guilty to two charges.
The first of the two charges related to the trust’s failures in Sarah’s care, while the other was for its failures in Wynter’s care.
The fine was reduced from £1.2m due to the guilty pleas, with the trust given two years to pay it, in addition to £13,668 in costs and a victim surcharge of £181.
Trust chief executive Anthony May said he was “truly sorry for the pain and grief” caused, adding: “We let them down at what should have been a joyous time in their lives.”
The trust said it had worked to address the findings and had implemented a number of changes to its maternity services, including increased investment in training and equipment.
Its maternity units have been rated inadequate since 2020 and are the subject of a wider review by senior midwife Donna Ockenden, who published a report into the biggest NHS maternity scandal in Shropshire last year.
The CQC, which also prosecuted East Kent NHS Trust for failures in the case of Harry Richford, called the death of Wynter “an absolute tragedy”.
Director of operations Lorraine Tedeschini said: “Mothers have a right to safe care and treatment when having a baby, so it is unacceptable that their safety was not well managed by the trust.
“I hope this prosecution reminds care providers they must always take all reasonable steps to ensure people’s safety, including responding appropriately when our inspections identify areas needing improvement.”
Ms Ockenden said the suffering of Wynter’s family should be “at the forefront of everyone’s mind”.
With more than 900 families and 400 staff speaking to her review about concerns over maternity care at the trust, she urged more to contact the investigation.
“The more staff that come forward, the more families we are able to include, the more robust our findings will be and the more relevant our findings will be, and the stronger our findings will be,” she said.