Donna Ockenden, the senior midwife leading the wide-ranging independent review into maternity failings at Nottingham's main hospitals, says her team will work to ensure lessons are learnt from the 'watershed' case of baby Wynter Andrews.
Baby Wynter died just 23 minutes after she was born at the Queen's Medical Centre in September 2019. On Friday (January 27), Nottingham University Hospitals NHS Trust (NUH) was fined a record £800,000 for failing to provide safe care to Wynter and her mum Sarah Andrews.
Wynter died after the umbilical cord had become wrapped around her neck and from acute chorioamnionitis - an inflammation of the placenta due to an infection. She had also suffered a haemorrhage to the brain and lung.
Read more: Nottingham Hospitals Trust boss apologises in case of Wynter Andrews and mum
Following the sentencing hearing, Ms Ockenden, who was last year appointed as the chair of an independent review into maternity failings at QMC and Nottingham City Hospital, said the review team will work with NUH to ensure lessons are learnt from such a tragic and high profile case.
"I think that what is at the heart of this tragic case is the loss and the grief that Sarah and Gary Andrews (Wynter's dad) and Wynter's baby brother will live with for the rest of their days," she said. "We cannot turn back the clock, we wish we could, and the need for a family to bury their baby is something that no one should ever have to do and clearly that is the situation that this Nottinghamshire family are in today.
"We know from the coroner's inquest that there were multiple failings in Sarah's care that contributed to the death of Wynter. What we will be doing as part of our review is ensuring that the trust are provided with a comprehensive list of lessons that must be learnt, and I stress they must be learnt.
"We will be working with the trust as we go through the review to ensure that they get lessons to be learnt on an ongoing basis. I want that to give confidence to the women and families of Nottinghamshire, it won't be a case of the trust being given lots and lots of things to do in 18 months' time.
"Where we identify that things have to change, we will be upfront and very honest about that on an ongoing basis. I'm aware that the trust is working really hard with its maternity improvement plan as we speak.
"But none of that, as Sarah Andrews said, can bring back Wynter because Wynter should be home with her mummy, daddy and little brother now and she isn't."
An inquest at Nottingham Coroner's Court in 2020 heard that staff failed to recognise Mrs Andrews was in established and not latent labour, failed to act on high blood pressure readings and carried out four "inaccurate and insufficient handovers" to colleagues as part of a catalogue of errors in the lead up to baby Wynter's death.
Midwives at the Queen's Medical Centre had told the inquest they were "overworked and understaffed", and said they didn't feel able to professionally challenge colleagues at the hospital. Assistant coroner Laurinda Bower had said: "These failures have a direct link to Wynter's death."
Health watchdog the Care Quality Commission brought legal action against NUH as a result. During the sentencing hearing at Nottingham Magistrates' Court, District Judge Grace Leong also ordered NUH to pay £13,668.65 in legal costs and a victim surcharge of £181.
Bernard Thorogood, a specialist barrister representing the interests of NUH, had entered two guilty pleas on behalf of the Trust - which has more than 17,000 staff and is a major employer in the city - at a previous court hearing on Wednesday (January 25). The charges concerned a failure to provide care and treatment in a safe way, resulting in harm or loss to Mrs Andrews and little Wynter, who died in her parents' arms after 23 minutes and 30 seconds of life.
In an emotional statement read outside the court, Mrs Andrews, who had husband Gary by her side, said they were not the only family harmed by NUH maternity failings. Bereaved families had called for the appointment of Ms Ockenden to lead an independent maternity review following widespread criticism of an initial 'thematic' review, which had been jointly commissioned by the local Clinical Commissioning Group and NHS England and was later scrapped.
More than 1,500 families are expected to be covered by the Nottingham review, which would make it the largest NHS maternity scandal in the UK, surpassing the 1,486 families examined during the maternity review led by Ms Ockenden in Shrewsbury.
The Shrewsbury and Telford review covered cases from more than 40 years, from 1973 to 2020, whereas the Nottingham review will investigate cases from 2012 onwards.
Ms Ockenden described the fine imposed on NUH as a "watershed moment for maternity services in Nottingham". She said: "We're in the very early stages of our review. The trust has identified over 1,000 cases that may well fall within our terms of reference, and more than 900 Nottinghamshire families have contacted the review, so we're looking through those two groups. We don't yet know the commonality between the two groups.
"I've had the privilege of meeting with Sarah and Gary Andrews on a number of occasions. I have heard their story, I've heard their account of what happened to them and to Wynter. What I would say to the women and families of Nottingham now is that many of you before Christmas will have received a letter from the trust with a letter from me attached.
"It is absolutely vital that you go and look for that letter if you haven't responded and give consent to join our review. At the moment, we can't ask the trust for your medical records if we don't know who you are.
"If you've lost the letter or misplaced it, just get in touch with us: firstname.lastname@example.org. Because the more cases that my team can consider, the more likely we are to get strong messages across to the trust about the learning that they must undertake.
"More than 400 members of NUH staff have come forward for our staff voices initiative. The level of staff engagement in these early days is excellent. Just over 90 staff engaged with us in Shrewsbury and Telford, so we've already got around four times that.
"I can't comment on the legal process and the judgement, but I understand why that legal process and that judgement has been handed down. I think we should refer back to the many many serious concerns that were raised within the coroner's inquest and that have been heard throughout the week. Clearly, today is a watershed moment for maternity services in Nottingham and our work continues on an ongoing basis."
The criminal prosecution of NUH brought on by the CQC follows a separate case last year when East Kent Hospitals University Foundation Trust was fined £761,000 over its failure to protect baby Harry Richford and his mum Sarah. NUH's maternity services at the City Hospital and QMC remain as having been rated 'inadequate' by the CQC.
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