Nottingham University Hospitals (NUH) NHS Trust has been fined £1.6 million after admitting to “avoidable failings” that contributed to the deaths of three babies in 2021. The babies—Adele O’Sullivan, Kahlani Rawson, and Quinn Parker—died shortly after birth while under the trust’s care. They all passed away within 14 weeks of each other.
The Care Quality Commission (CQC) brought the prosecution, and NUH pleaded guilty to six counts of failing to provide safe care to the babies and their mothers. On Wednesday, district judge Grace Leong expressed her condolences to the families, acknowledging that their trust in the healthcare system had been shattered.
Adele died just 26 minutes after birth on April 7, 2021, Kahlani passed away at four days old on June 15, and Quinn died at just two days old on July 16.
In a statement outside Nottingham Magistrates’ Court, Quinn’s parents, Emmie Studencki and Ryan Parker, said that while the prosecution wouldn’t bring their son back, his voice had been heard. “Quinn died from a long list of failings,” their lawyer, Natalie Cosgrove, said. “Some failings so basic that even a stranger on the street would have provided better care.”
Sadie Simpson, speaking for Adele and Kahlani’s families, said the prosecution should be a “turning point” and further acknowledged the serious failures in care. The fine, the largest ever issued for maternity care failings, was reduced from £5.5 million due to the trust’s financial situation and its guilty pleas.
The judge described a “catalogue of failures” in all three cases. These included issues with staff training and equipment, delays in recognizing serious conditions, and substandard handover processes. In each case, the mothers experienced a placental abruption—a serious condition where the placenta detaches from the womb. The court heard that staff were often unprepared to interpret CTG results, which monitor fetal heart rate and contractions.
NUH had been placed in “special measures” by the CQC after an inspection in October 2020, and while improvements were noted in April 2021, the babies died soon after.
The judge noted that the families had placed their trust in a system meant to protect mothers and babies, but that trust had been broken. “Their grief remains raw,” the judge added, emphasizing that the impact of the trust’s failures would linger forever.
Adele’s mother, Daniela O’Sullivan, had suffered bleeding and abdominal pain before an emergency C-section was performed, but no vaginal examination was done, and the labor was not identified in time. In Kahlani’s case, her mother, Ellise Rawson, had reported a lack of fetal movement, but key information about her condition wasn’t passed on. A coroner confirmed that this delay contributed to a 20-minute wait for the C-section.
In Quinn’s case, his mother had been to the hospital multiple times due to bleeding before being rushed in for a C-section. Medical records showed that Quinn was born pale and floppy, and an inquest found errors contributed to his death.
The trust is currently undergoing the largest maternity review in NHS history, examining around 2,500 cases. It has been prosecuted twice by the CQC, having previously been fined £800,000 in 2023 for failures related to another baby’s death in 2019.
The trust, which has an annual turnover of £612 million, is facing significant financial strain with a £100 million deficit. The judge acknowledged the financial burden but stated that the penalty must reflect the seriousness of the failures.
NUH has also been ordered to pay prosecution costs of £67,755 and a surcharge of £190. After the ruling, NUH chief executive Anthony May expressed regret, apologizing to the families and the staff who had been let down by the trust’s failures. He assured that improvements had been made to ensure safer maternity services.
Helen Rawlings, CQC’s director of operations, stressed that this was the second prosecution of NUH for failures in its maternity services and emphasized that the CQC would continue to monitor the trust closely to ensure improvements are maintained.
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