£800k fine is ‘clear message’ patient safety must be priority, says mother

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.

“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.

“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, she added she was “acutely aware” that the trust’s funds were accounted for that and that it was already operating in a deficit, stating that the negative impact of any fine on patient care must be accounted for.

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.

“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.

The maternity services at QMC were rated as inadequate following the CQC’s most recent inspection in May 2022, with the hospital being rated as requiring improvement. The trust overall was rated as requiring improvement in its last inspection in 2021.

Lorraine Tedeschini, director of operations in the Midlands for the CQC, said:
“The death of Wynter Andrews is an absolute tragedy and my thoughts are with her family and all those grieving their loss.

“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.

“The vast majority of people receive good care when they attend hospital, but whenever a provider puts people in its care at risk of harm, we take action to hold it to account and protect people.

“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.”