Nottingham University Hospitals NHS Trust has been ordered to pay a total of £1,667,944 after pleading guilty to six charges of failing to provide safe care and treatment to three mothers and their babies, following a sentencing hearing today (Wednesday 12 February) at Nottingham Magistrates’ Court, in a prosecution brought by the Care Quality Commission (CQC).
CQC has prosecuted the trust after mistakes it admitted meant the following three mothers and their babies, did not receive safe care and treatment in its maternity services at Nottingham City Hospital:
- The first case relates to Daniela O’Sullivan and her baby Adele O’Sullivan, who died shortly after her birth on 7 April 2021. The trust was prosecuted for exposing Daniela and Adele to a significant risk of avoidable harm. This resulted in two offences under Regulations 12 and 22(2)(b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
- The second relates to the care and treatment of Ellise Rawson, as well as her baby, Kahlani Rawson. Kahlani died on 15 June 2021, four days after being born. Again, the trust was prosecuted for exposing both mother and baby to a significant risk of avoidable harm. This also resulted in two offences under Regulations 12 and 22(2)(b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
- CQC also prosecuted the trust for causing avoidable harm to baby Quinn Lias Parker, who died at one day old, on 16 July 2021, and for exposing his mother Emmie Studencki to significant risk of avoidable harm. This resulted in one charge of Regulations 12 and 22(2)(a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 for baby Quinn and one charge of Regulations 12 and 22(2)(b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 for Emmie Studencki.
The trust admitted it did not provide safe care and treatment to these mothers and their babies, in that it failed to ensure that adequate processes and systems were in place and implemented to ensure that all risks to their health and wellbeing were appropriately managed. This exposed them to a significant risk of avoidable harm.
Daniela and Adele O’Sullivan
Daniela, aged 39 and in her second pregnancy had consultant-led care due to her previous history and was being monitored closely.
An investigation found multiple failings and missed opportunities in Daniela’s care from when she attended Nottingham City Hospital on 28 March 2021, until the birth of Adele on 7 April 2021. Sadly, Adele died shortly after she was born.
In pleading guilty to the offences, the trust admitted several failures in the care of Daniela and Adele arising from various delays and missed opportunities, as well as not following policies.
The failures in care included:
- A lack of appropriate escalation of care and Cardiotocography (CTG) monitoring. This is a continuous recording of the fetal heart rate via an ultrasound.
- Hospital staff did not communicate properly during the handover.
- There was a failure to deliver Adele in a timely manner once Daniella had been transferred to the delivery suite.
The trust admitted that underlying failures, in relation to its systems and processes in place at the time, led to the failures in the delivery of care to Adele and Daniela which exposed them to a significant risk of avoidable harm.
For Daniela, the court ordered the trust to pay a £100,000 fine and £300,000 for baby Adele, as well as £26,178 costs to the Care Quality Commission (CQC), which prosecuted these criminal offences.
Ellise and Kahlani Rawson
Ellise was having consultant led care due to her age. Her due date was 2 July 2021.
She went to Nottingham City Hospital on 1 and 2 June 2021 due to having reduced fetal movement. Following assessments taking place, Ellise was discharged home as she was told the results looked normal.
Then on 11 June 2021 she went back to the maternity unit with abdominal pains and no fetal movement for 24 hours. She was reviewed, however no formal assessment of the CTG took place.
Evidence showed there were various failings in relation to the CTG monitoring for both Ellise and baby Kahlani from 11 June 2021, when she arrived at the hospital, until Kahlani’s death on 15 June 2021.
The failures in care included:
- Abnormal CTG readings were not handed over to the consultant obstetricians.
- A decision to deliver Kahlani should have taken place earlier due to the abnormal fetal heart rate patterns.
- There was a failure to assess the risks to the health and safety of mother and baby when she presented with what was clearly a placenta abruption.
The trust admitted that underlying failures, in relation to its policies and procedures in place at the time, led to the failures in the delivery of care to baby Kahlani and his mother, which exposed them to a significant risk of avoidable harm.
For Ellise, the court ordered the trust to pay a £100,000 fine and £300,000 for baby Kahlani, as well as £19,443 costs to the Care Quality Commission (CQC), which prosecuted these criminal offences.
Emmie Studencki and Quinn Lias Parker
Emmie Studencki was 31 years old when she booked her second pregnancy with her midwife, with an estimated due date of 5 August 2021.
On three occasions in July, Emmie was admitted to the maternity unit due to having a bleed. On each occasion she was given some advice and discharged home.
Then on 14 July 2021 Emmie had another haemorrhage and called an ambulance to take her to hospital. Later that day, a decision was made to induce labour and baby Quinn Lias Parker was born the same day. He was transferred to the neonatal unit and sadly died on 16 July 2021.
There were a number of failures by the trust in the care and treatment that Emmie and baby Quinn received during her visits to the hospital in the days leading up to Quinn’s birth, and up until his death.
The failures in care included:
- Lack of adequate information provided to Emmie when she was discharged from hospital after earlier admissions, so she knew what signs to look out for.
- Failure to record and appreciate the true extent of Emmie’s blood loss by hospital staff, and a lack of adequate communication between ambulance and hospital staff regarding Emmie’s blood loss.
- Failure to ensure that the trust had an appropriate process in place to ensure that the written handover from the ambulance staff formed part of the hospital records for Emmie, or that appropriate detail from the ambulance staff handover was recorded by hospital staff in the records.
- Not adequately involving Emmie in decisions about her care.
- The trust’s overall approach to CTG monitoring and interpretation was inadequate, as it was not operating effectively.
The trust admitted that it did not have a system which was always effective for handover of people’s information when transferring between the ambulance service and the maternity unit. The trust also accepted that hospital staff did not document the estimated blood loss, or several other factors reported to them by the ambulance staff which led to the failures in the delivery of care to Emmie and Quinn.
For Emmie, the court ordered the trust to pay a £100,000 fine and £700,000 for baby Quinn, as well as £22,133 costs to the Care Quality Commission (CQC), which prosecuted these criminal offences.
In addition to the £1.6 million fine, and £67,755 costs, the court ordered the trust to pay a £190 victim surcharge as well.
The size of the fine is a decision made by the court and is informed by sentencing guidelines. The fine was reduced from £5.5 million due to the trust’s early guilty pleas as well as other factors. CQC does not have influence over this decision.
Helen Rawlings, CQC’s director of operations in the midlands, said:
“The care that these mothers received, and the death of these three babies is an absolute tragedy and my thoughts are with their families and all those grieving their loss under such sad circumstances.
“All mothers have a right to safe care and treatment when having a baby, so it’s unacceptable that their safety was not well managed by Nottingham University Hospitals NHS Trust.
“The vast majority of people receive good care when they attend hospital, but whenever a registered health care provider puts people in its care at risk of harm, we seek to take action to hold it to account and protect people.
“This is the second time we have prosecuted the trust for not providing safe care and treatment in its maternity services, and we will continue to monitor the trust closely to ensure they are making and embedding improvements so that women and babies receive the safe care they deserve.”
CQC carried out an inspection in maternity services at Nottingham City Hospital and Queen’s Medical Centre last year, and the findings from this will be published on CQC’s website once it has gone through the required quality assurance processes.
An independent review is also being carried out by Donna Ockenden into failings at the trust’s maternity services.