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An NHS trust has been fined £1.6m after admitting it failed to provide safe care and treatment to three babies who died within months of one other – the first time a trust has been prosecuted more than once for maternity failures.
Nottingham university hospitals NHS trust (NUH) pleaded guilty on Monday to six counts in relation to the deaths of Adele O’Sullivan, Kahlani Rawson and Quinn Parker, who all died shortly after being born, and the treatment of their mothers.
NUH, which is at the centre of the largest maternity inquiry in the history of the NHS, is the first trust to be prosecuted by the Care Quality Commission (CQC), the healthcare watchdog, more than once. In 2023 it was fined £800,000 for failures in the care of Wynter Andrews, who died 23 minutes after being born at Queen’s Medical Centre in Nottingham in September 2019.
On Monday, Nottingham magistrates court was told that “serious and systemic failures” exposed all three mothers and their babies to significant risk of avoidable harm.
The court heard that Adele O’Sullivan was born on 7 April 2021 at 29 weeks after an emergency caesarean at Nottingham’s City hospital after her mother, Daniela, a high-risk patient, noticed bleeding and developed abdominal pain.
She was not examined for eight hours before Adele was born, and said she was left “screaming in pain” with no painkillers, despite having a high-risk pregnancy.
Adele was born in “poor condition” and she died at 26 minutes old. A postmortem found she died as a result of severe intrapartum hypoxia, a condition caused by a lack of oxygen to the baby during labour and delivery.
“People who were supposed to help me did not help but harmed me mentally and physically for ever,” O’Sullivan said in a victim impact statement. “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.”
Kahlani Rawson died on 15 June 2021 at four days old from hypoxic ischemic encephalopathy, a brain injury that occurs when a baby’s brain doesn’t receive enough oxygen or blood flow. His mother, Ellise Rawson, reported to the hospital with abdominal pain and reduced foetal movements but there was a delay in performing an emergency caesarean section.
Kahlani’s grandmother, Amy Rawson, told the court her grandson’s death was a “preventable tragedy” that left the family “devastated, broken and numb”.
The court was also told Quinn Parker’s mother, Emmie Studencki, went to hospital four times before her son was born after having bleeding.
Studencki called an ambulance on 14 July 2021 and paramedics estimated she lost about 1.2 litres of blood at home and in the ambulance on the way to City hospital. This did not “find its way into the hospital’s notes”, with staff recording only a 200ml blood loss.
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Quinn was “pale and floppy” when he was born via emergency caesarean section that evening, and despite several blood transfusions he was pronounced dead on 16 July 2021 after suffering from 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.
Studencki said the trust’s treatment of her, her son and her partner, Ryan Parker, was “contemptuous and inhumane”.
“We had an expectation of dignity and respect. We expected to be treated as humans,” she said in a statement. “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” and that improvements had been made, including hiring more midwives and providing further training to staff.
