An NHS trust has been fined £800,000 for a “catalogue of failings and errors” that led to the death of a baby 23 minutes after she was born.
Wynter Andrews died in the arms of her parents, Sarah and Gary Andrews, on 15 September 2019 due to a lack of oxygen to the brain, shortly after an emergency caesarean section at the Queen’s Medical Centre (QMC) in Nottingham.
Nottingham University Hospitals (NUH) NHS Trust had admitted two counts of failing to provide safe care and treatment resulting in harm and loss at a court hearing on Wednesday.
Meanwhile, it has emerged more than 900 families and more than 400 staff have contacted a wide-ranging investigation being led by senior midwife Donna Ockenden into maternity care across the trust following concerns raised by several families.
Sentencing at the city’s magistrates’ court on Friday, District Judge Grace Leong 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.
“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.”
District Judge Leong added the “systematic failures” were “more than sufficient” to cause harm to Wynter and her mother.
She said the total fine, combining the sums for offences against both Wynter and Mrs Andrews, would have been £1.2m, but this was reduced to £800,000 due to the trust’s early guilty pleas.
The judge also said she was “acutely aware” any fine would have to be paid out of public funds which would otherwise be spent on patient care.
The trust, which will pay prosecution costs of £13,668.65 and a victim surcharge of £181, has asked for two years to pay the fine.
Why maternity scandals keep happening
Baby deaths mystery from 1930s solved
Speaking outside the court, Mrs Andrews said: “These criminal proceedings are designed to act as a punishment and a deterrent. No financial penalty will ever bring Wynter back.
“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.”
Mrs Andrews has previously said she was “failed in the most cruel way” by the trust and its management had been “repeatedly warned by staff about safety at the unit” but “failed to act”.
She urged other mothers who may have been through similar experiences to take part in the Ockenden review.
In a statement, trust chief executive Anthony May said: “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.”
He added: “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 prosecution had been brought by the Care Quality Commission (CQC).
The maternity services at QMC were rated as inadequate following the CQC’s most recent inspection in May 2022, with the hospital being judged as requiring improvement.
The trust overall was rated as requiring improvement in its last inspection in 2021.
Lorraine Tedeschini of 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.”
She added: “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.”