Special report: Grieving parents were told their tragedies on the maternity wards of Nottingham hospitals were one-offs. But our investigation shows a pattern of poor care, botched inquiries and a failure to learn the lessons that could keep mothers and their newborns safe. Shaun Lintern reports
Dozens of babies have died or been left brain-damaged after errors during childbirth at one of Britain’s biggest hospitals – while managers failed to properly investigate concerns and altered reports to take blame away from the maternity unit.
An investigation by 独立 and Channel 4 News has uncovered repeated examples of poor care over the past decade at Nottingham University Hospitals NHS Trust, with parents forced to fight to find out the truth about what happened to their child.
Families say that if lessons had been learnt, further tragedies at the hospital could have been prevented. Naomi Lewin, whose baby Freddie died after a harrowing labour, 告诉 独立: “They don’t listen to families. It’s ignorance. If they don’t learn from it, it’s going to be a repeat cycle over and over and over again.”
During a panicked delivery, Freddie’s throat was cut during an attempt to free him and his leg was so bruised it had become blackened. He died soon after birth with no post-mortem examination despite the traumatic injuries. In another case, a baby died hours after being discharged from hospital despite the mother’s concerns that he had never cried or fed since birth.
Nottingham, which has one of the largest NHS budgets in the UK, is currently facing at least a dozen clinical negligence claims by bereaved families and it can be revealed today that the trust has already paid out more than £91m in damages and legal costs since 2010, 包括 46 cases of babies left with permanent brain damage and 19 stillbirths as well as 15 死亡人数.
The trust chief executive today apologised to families and said improvements were being made.
Documents seen by 独立 show that, in some instances, key medical notes were missing or never made, while others were completely inaccurate. 这 国民保健服务 trust failed to properly investigate some deaths for months and, in instances when it did, details were wrong or reviews were watered down by senior management to lessen the criticism.
A draft report into the death of baby Harriet Hawkins in 2016 was changed from concluding that her death had been “directly contributed to” by errors to saying her death “might have been avoided”.
The Nottinghamshire coroner was also told some deaths were “expected” when it later emerged they had been caused by serious neglect. As recently as 2020, the death of a mother after giving birth was labelled as a “low harm” incident.
The avoidable deaths and injuries combined with fears of a lack of action have drawn parallels with maternity units at Shrewsbury and East Kent hospitals, both of which are the subject of independent inquiries. Since revealing the scale of the Shrewsbury maternity scandal,独立 has campaigned for safer maternity care across the NHS.
Now a whistleblower has told 独立 that a “Teflon team” on managers allowed staffing shortages to build up to dangerous levels, while pleas from midwives were ignored and incidents “swept under the carpet”.
‘Swept under the carpet’
Sue Brydon, who worked as a senior clinical midwife at the trust from the 1980s until her retirement at the end of 2019, said her confidence in the management nosedived to the point she instigated a letter to the trust board in 2018, signed by midwives and doctors, warning of fears for patient safety due to staff shortages.
信, which became public last year during an inquest into the death of baby Wynter Andrews, raised “grave concerns” for patients and staff and said the senior leadership at the trust had not listened to fears that staffing levels risked “potential disaster”.
At that stage there were 35 vacant full-time midwife posts. In December last year, when the CQC declared the maternity unit’s care “inadequate”, this had risen to 73.
Speaking publicly for the first time, Ms Brydon said she was “absolutely raging” towards managers when she left the trust: “We used to call them the Teflon team. You couldn’t get through to them. The Teflon team refused to do anything.”
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When incidents occurred, it rested on individual doctors and midwives to flag the cases which she said were then screened and discussed at risk meetings where decisions would be made if an investigation was needed.
“Quite a lot of the time when I was on that [committee], there were things that were clearly awful, that should have been triggering statements from staff, that were just swept under the carpet for whatever reason; it was someone’s friend etc. That didn’t happen very often. But it did happen.”
After the 2018 letter to the trust board, she said nothing was done: “We were supposed to have a series of meetings; we had one meeting. All we got was the head of midwifery saying that there wasn’t really a problem.”
The trust claims a series of “workshops” were held with staff following the letter to the board, although staffing levels worsened between 2018 和 2020.
Ms Brydon remains in contact with staff working at the trust now and said people were scared. 她说: “There’s a real culture of fear that still exists because everybody feels their registration is on the line if they put their head above the parapet and say anything. My impression is that it is safe, but only because of the extra effort put in by the staff.”
Baby Thomas Seddon was stillborn in May 2017 after a midwife employed by the trust failed to refer his mum Sarah, an NHS pharmacist, straight to hospital after concerns he had stopped moving in the womb. Sarah should have had a full check-up and heart monitoring but this was not done. The midwife later told an investigation by the trust that Sarah had refused a blood pressure and urine check and was advised to go to hospital, which Sarah said was not correct.
The trust did not involve Sarah in this investigation and the paperwork had multiple inaccuracies. A second investigation after Sarah’s complaint resulted in a written apology acknowledging the trust had breached the duty of candour around transparency with families. The midwife involved received an official caution from the Nursing and Midwifery Council.
‘The signs were there’
Data obtained by 独立 显示 201 clinical negligence claims against the trust’s maternity services since 2010, with almost half lodged in the last four years.
Of the 84 closed cases, the NHS paid out £79.3m in compensation, and a further £12.3m in legal costs. The true value of the negligence claims is likely to be significantly higher as data may exclude future payments to support the lives of disabled children.
在里面 201 要求, there were 15 死亡人数, 19 stillbirths, 46 cases of brain damage and 18 cases of cerebral palsy. 总计 25 cases were caused by delays in treatment, another 15 by a failure to respond to an abnormal foetal heart rate and 13 attributed to complications not being recognised.
There were also 12 delays or failures to diagnose conditions, 10 cases of inadequate nursing care, and a total of 16 cases involving staff who failed to monitor the second stage of labour when women were actively giving birth. This latter category alone cost the NHS £16m.
An analysis of hospital patient data for maternity, comparing Nottingham Hospitals to more than 20 other similar major hospitals, showed the trust had a consistently above-average rate of spontaneous, or natural, birth, compared with other trusts for every year since 2010.
Its rate of instrumental births switched from being above average until 2013 to below average every year since – similarly since 2010 the trust has had fewer emergency caesarean sections every year than the average.
This data could suggest that women are being left longer to achieve a natural birth at Nottingham than other larger hospitals, potentially increasing risks for those who get into difficulty.
Shrewsbury and Telford Hospital NHS Trust had the highest natural birth rate in England during five out of the eight years between 2010 和 2018 and was among the top three in the remaining years.
East Kent Hospitals University NHS Foundation Trust was fined a record £761,000 earlier this month over failings in the care of baby Harry Richford.
One Nottingham trust manager who asked to remain anonymous said: “The signs were there, along with not just poor-quality investigations and things that just remained unanswered, but some inappropriate behaviours in maternity as well.
“I think the board didn’t piece together a number of things soon enough to realise the scale of the problem.”
‘Someone has to take control’
去年, the Care Quality Commission identified a failure of staff to “interpret, classify and escalate” concerning heart rate traces for babies. The watchdog said there had been incidents where staff failed to monitor heart rates or had misinterpreted the readings, leading to cases where babies suffered harm or death as a direct result.
From July to September last year there were 488 incidents in maternity at the trust, with three classed as severe harm, six as moderate harm and 477 as low or no harm. The CQC said it found a number of incidents had been “inappropriately graded” where, 例如, babies or women who needed intensive care were labelled as “low harm”. In one case the death of a mother was labelled “low harm”.
In its latest inspection, published in May, the CQC said the trust had made progress but more improvements were necessary. The service remains rated as inadequate.
The regulator has said it has concerns about maternity safety units across the country, telling 独立 41 per cent are rated as inadequate or requiring improvement on safety.
Natalie Cosgrove, an associate at Switalski’s Solicitors, which is representing more than a dozen families in legal claims against the trust, said the problems had created a “collective grief” for families every time they see another family suffering.
她补充说: “We have had many families contact us. There is an embedded cultural problem within maternity services at Nottingham and despite the fact staff members have raised concerns, there doesn’t seem to be any substantial changes to those cultural issues.
“When families have raised genuine concerns and suggestions for improvement these have been rebuffed. The trust is failing to learn from its mistakes and at some point, someone external has to take control so more families don’t follow the same patterns.”
The trust told 独立 it had a major programme to improve maternity services which included a focus on culture, learning and better governance. Work includes better training for midwives on monitoring women and babies and assessing their risk as well as ongoing recruitment of midwives and obestetricians.
在 2019 it carried out a review of its duty of candour process and launched extra training for staff.
The chief executive of Nottingham University Hospitals NHS Trust, Tracy Taylor, 说: “We apologise from the bottom of our hearts to the families who have not received the high level of care they need and deserve, we recognise the effects have been devastating.
“Improving maternity services is a top priority and we are making significant changes including hiring and training more midwives and introducing digital maternity records. We will continue to listen to women and families, whether they have received excellent care or where care has fallen short; it is their experiences that will help us to learn and improve our services.”