Nottingham hospitals’ maternity care failings review to be largest in NHS history

A review into widespread failings in maternity care at Nottingham hospitals will be the largest in NHS history.

Donna Ockenden, chair of the inquiry, told a meeting on Monday, July 10 that 1,700 families’ cases would now be examined.

The review focuses on the maternity units at the Queen’s Medical Centre and City Hospital, both run by Nottingham University Hospital NHS Trust, after dozens of baby deaths and injuries.

Chair of the Trust board Nick Carver made a statement on behalf of the board at the Annual Public Meeting, admitting a “brick wall” approach has harmed families further.

Chief Executive Anthony May said it was a “milestone” moment.

‘Very long journey ahead’

Bereaved parents Dr Jack and Sarah Hawkins, Gary and Sarah Andrews, Ama and Sharma Maduako and Natalie Needham shared their own stories of poor care with Trust bosses.

It comes after the Department of Health and Social Care, NHS England and the Trust have agreed to change the review from ‘opt-in’ to ‘opt-out’.

Ms Ockenden told the audience: “All known families will now be contacted individually by my review team and they can make their own choice whether to join the independent review or not.

“Already I am seeing some positive change, but the Trust has a very long journey ahead. What has happened cannot be fixed overnight.

“Today there’s likely to be a lot of conversations about the numbers who are involved in the review. But please can all of us remember that behind every number is a family who has suffered harm, often avoidable and life-changing harm, made worse by having to fight to be heard.

“I know there are local families struggling to provide 24-hour care for severely brain-damaged babies. I have spoken to a mother whose baby is so poorly, she asks herself on a regular basis, would it have been better if my baby passed away?

“I know there are families who never brought their baby home.

“I know there are little boys and girls out there in Nottinghamshire today without their mummy. I know there are women living with life-changing harm.”

‘Completely preventable’

At the meeting, Sarah Hawkins explained how her daughter Harriet died in 2016.

She said: “Her death was completely preventable. We had to fight for multiple investigations. In 2016 as utterly broken parents and two senior clinicians at the Trust, we blew the whistle loudly.

“In 2017 we met the current medical director and we said ‘you’re acting like Mid- Staffs and you are conducting a cover-up’.”

In 2013, a public inquiry into hundreds of deaths at Stafford Hospital, run by Mid Staffordshire NHS Foundation Trust, found poor care and unacceptable standards.

Ms Hawkins added: “How can the Trust offer reassurance of an honest and transparent relationship when current members of the board and clinicians who helped with the cover-up are still in post?”

Mr May apologised to Mrs Hawkins and said: “There is a fit and proper person test for people that serve here in board positions.

“Donna’s review in itself is intended to shine a light on those things.

“If there are things Donna says we should’ve done differently, including people that work in the Trust no matter what their role, we will absolutely respond to that.”

Cllr Michelle Welsh, who sits on the health scrutiny committee at Nottinghamshire County Council, said during the meeting: “The Trust has avoided scrutiny with regard to maternity services at every single step of the way.

“It has taken the most traumatised yet strong and courageous families to stand up.”

‘Devastating’

Speaking after the meeting, Natalie Needham, whose son Kouper died in 2019, said she found it “hard” to build back trust with the organisation after her experience.

“If they would’ve taken me seriously, we could still have our child,” Ms Needham said.

“That’s what I want the Trust to learn. Their decision not to listen to a mother has had a devastating effect on my family. It’s not just me, it’s my parents, my other children and my son I had since Kouper died.

“We need answers for them because if maternity services don’t change now, and my children go on to have children, what chance do they have?”

Chief Executive Anthony May told the Local Democracy Reporting Service that he was “pleased” the review has been changed to an ‘opt out’ method.

He said: “We need as many families in the review as possible.

“What really matters is that it’s a good review and what comes out of it changes maternity services for the better, not just here but across the country.

“It is tinged with sadness because behind those 1,700 is a range of very sad stories where people have been hurt and sometimes lost their loved ones.

“I know that the organisation I am at the helm of was partly responsible for that.

“[This] is a milestone for us as a Trust but also I hope for the families.”

‘Honesty pledge’

He added that the health watchdog the Care Quality Commission has recently visited the Trust and a final report will be published in September.

Nick Carver, chair of the board, told the audience: “On behalf of the Trust board I commit the Trust to a new honest and transparent relationship with the families whose lives have been affected by maternity failings at the Trust.

“For too long we have failed to listen to women and families who have been affected by failings in our maternity services. This ‘brick wall’ has caused additional pain, and this must change.

“Families should not have to fight to get the answers they deserve and we are committed to gaining their trust, and the trust of all our communities by listening and engaging with them.

“Some families, who we have had the chance to meet, have told us they want a meaningful apology that they recognise as meeting their needs, including accountability and a change in the culture. We will work with them and other families to make that happen.”