Sarah and Gary Andrews’ daughter Wynter died 23 minutes after being born in 2019. Nottingham University Hospitals NHS Trust was fined £800,000 after admitting failings. On Wednesday, the largest maternity review in NHS history revealed that Wynter was one of 520 mothers and babies who suffered “potentially avoidable” harm or death at the trust.
Led by senior midwife Donna Ockenden, the inquiry found 444 women and 76 newborn babies experienced substandard care spanning 13 years. The cases included 94 stillbirths, 62 neonatal deaths, 120 brain injuries and nine children left with cerebral palsy. Six maternal deaths were deemed potentially avoidable. Assessors found babies died from oxygen starvation, mismanaged labour, hospital-acquired infections and poor postnatal care.
“More than 500 mothers and babies suffered avoidable harm or death at Nottingham NHS trust in UK's biggest maternity scandal.”
“This is a report about how a system failed, and what it costs when it fails,” Ockenden said at the Crowne Plaza hotel in Nottingham. “It costs lives, futures and families, everything.”
The 401-page document paints a picture of “deeply embedded systemic failures” and a “bullying and toxic culture”. Staff described “intimidating cliques” that went unchallenged. Vulnerable women were “systematically dismissed”, with some accused of “imagining pain”. The report found “recurring examples of failure to protect the dignity of the deceased, including an early gestation baby disposed as clinical waste; dehumanising language by clinicians; and poor mortuary care”.
Leaders at the trust knew there were serious issues for years but failed to act. Of 66 former and current senior colleagues approached by the chief executive, only 37 came forward and 35 were interviewed. Some management refused to engage, prompting the government to announce an extension of Martha’s Rule – giving families 24/7 access to a second opinion – to all maternity units in England. Staff who refuse to give evidence to future reviews could face up to two years in prison.
Sarah Hawkins, whose baby Harriet died in 2016, told the BBC it was “soul-destroying” to learn the deaths were potentially preventable. Sarah Andrews, 41, said: “All we’ve wanted from the beginning is that no other families have to endure what we have.” Her husband Gary, 38, called the report “a wake-up call to the NHS”. Ockenden urged that victims’ voices become “a catalyst for lasting national change”, adding: “Safe maternity care is not complicated in its ambition – competence, honesty, timeliness, safety, dignity and kindness are not high bars.”