Nottingham NHS Trust fined £1.6 million for failing to provide safe care to babies who died after birth
Nottingham University Hospitals NHS Trust entered guilty pleas in court on Monday
Last updated 12th Feb 2025
Nottingham University Hospitals NHS Foundation Trust has been fined £1.6 million after it admitted failing to provide safe care and treatment to three babies, who died in Nottingham in 2021 soon after being born.
It is the second time it has been prosecuted for maternity failures.
After entering guilty pleas on Monday to six counts in relation to the deaths of Adele O'Sullivan, who was 26 minutes old when she died on April 7 2021, four-day-old Kahlani Rawson, who died on June 15 2021 and Quinn Parker, who was one day old when he died on July 16 2021 - and the treatment of each of their mothers.
"Serious and systemic failures"
During the hearing, Nottingham Magistrates' Court was also told that "serious and systemic failures" exposed all three mothers and their babies to significant risk of avoidable harm.
The CQC who are prosecuting, says the trust did not ensure safe care and treatment due to a lack of adequate systems and processes being in place or not being appropriately implemented to ensure staff managed all risks to mothers and babies' health and wellbeing.
The court heard Adele O'Sullivan was born following an emergency Caesarean at 29 weeks at Nottingham City Hospital after mother Daniela, a high-risk patient, noticed bleeding and suffered abdominal pain.
"We lost our beautiful daughter."
Despite this, vaginal examinations were not performed, delaying recognition that Mrs O'Sullivan was in labour and delaying the diagnosis of her bleeding.
Adele was born in "poor condition" and a decision was made to withdraw care, with a post-mortem finding she died as a result of severe intrapartum hypoxia.
In a victim impact statement read to the court, Mrs O'Sullivan said she was left "screaming in pain" with no painkillers and despite having a high-risk pregnancy, was not examined for eight hours before Adele was born.
She said: "People who were supposed to help me did not help but harmed me mentally and physically forever.
"We lost our beautiful daughter. Instead of bringing her home I had to leave the labour suite empty handed in a lot of physical and mental pain.
"We will forever be thinking about her and our family will never be complete."
The court also heard Ellise Rawson reported to the hospital with abdominal pain and reduced foetal movements, but there was a delay in performing an emergency Caesarean section and her son Kahlani died of hypoxic ischemic encephalopathy after four days.
A "preventable tragedy"
Kahlani's grandmother Amy Rawson told the court on Monday that her grandson's death was a "preventable tragedy" that left the family "devastated, broken and numb".
The court was also told Emmie Studencki went to hospital four times before her son Quinn was born after suffering bleeding.
On the final occasion before Quinn was born, Ms Studencki called an ambulance at around 6.15am on July 14 2021 with paramedics estimating she had lost around 1.2 litres of blood both at home and in the ambulance on the way to City Hospital.
Despite this, the paramedics' observations did not "find its way into the hospital's notes", with staff only recording a 200ml blood loss.
It was a "possibility" he would have survived...
Quinn was "pale and floppy" when he was born via emergency Caesarean section that evening, and despite several blood transfusions, he was pronounced deceased after suffering multiple organ failure and lack of oxygen to the brain.
An inquest into Quinn's death concluded it was a "possibility" he would have survived had a Caesarean section been carried out earlier.
In a statement, Ms Studencki said the trust's treatment of her, her son and her partner Ryan Parker had been "contemptuous and inhumane" and they had been left broken.
She said: "We had an expectation of dignity and respect. We expected to be treated as humans.
"We as a family have been left behind, stranded in our grief. We are still chasing the full truth and accountability."
Counsel acting on behalf of the trust told the families in court they offered their "profound apologies and regrets" to those affected and that improvements have been made, including hiring more midwives and providing further training to staff.
"I am truly sorry"
The Chief Executive Anthony May previously said: “The mothers and families in these cases have had to endure things that no family should after the care provided by our hospitals failed them, and for that I am truly sorry. These families have shown incredible strength during this time, and I can only imagine how painful it must have been for them to share their experiences again.
“The Trust recognises the concerns raised by the CQC and has acted upon them to improve the services we provide to women and families in our care. The changes made mean that we are working in a different environment than 2021 and we believe that we now have a safer and more effective maternity service.”
The improvements made:
- Increased fetal monitoring training and support in clinical areas means the care provided for mothers and babies at NUH is now safer.
- Guidelines and protocols have been updated and made more accessible and visible to staff, leading to improved recordings of cardiotocography (CTG) monitoring.
- Handover processes have been improved, with a more joined-up approach across services using verbal and written updates and meetings to ensure all staff, including consultants, can manage patient safety, reduce the likelihood of information being missed or misinterpreted, and manage staffing levels throughout the day.
- Investment and training into the development and recruitment of maternity staff has seen a significant increase in staffing numbers on our wards and a positive reduction in the number of staff leaving the Trust. This translates to a safer maternity service for babies, mothers, and our staff.
The Trust also say in a 2023 CQC report, where the overall maternity rating was improved, the CQC recognised that cardiotocography (CTG) monitoring for women, which was highlighted as an area of concern in these cases, was now completed appropriately and was documented in line with national guidance.
Meanwhile the Trust, is currently at the centre of the largest maternity inquiry in the history of the NHS - and is now the first to be prosecuted by healthcare watchdog the Care Quality Commission more than once after it was earlier fined £800,000 in 2023 for failures in the care of Wynter Andrews, who died 23 minutes after being born at the Queen's Medical Centre in Nottingham in September 2019.