Nottingham Magistrates Court has fined Nottingham University Hospitals NHS Trust (‘NUH’) £1.6m following the Trust’s failure to provide safe care and treatment to three babies and their mothers. The court found that a ‘catalogue of failures’ by the Trust led to the deaths of Adele O’Sullivan, Kahlani Rawson and Quinn Parker in 2021.

NUH admitted six counts of failing to provide safe care and treatment to the babies and their mothers, following a prosecution brought by the Care Quality Commission (‘CQC’). The £1.6m fine given by the court on Wednesday 12 February is the largest ever for an NHS trust for maternity care. This is the second time that the CQC has charged the Nottingham trust over failures in maternity care.

District Judge Grace Leong commented that “it is very difficult, if not impossible, to move on from the failures of the trust and its maternity unit.”

The judge deemed the failures in the NUH’s maternity ward as avoidable and resulted from the lack of adequate systems in place to ensure Trust staff managed the risks to the babies and their mothers.

The court heard from Daniela, mother of Adele O’Sullivan, who stated that “people who were supposed to help me did not help, but harmed me mentally and physically forever”. She was left “screaming in pain” with no painkillers and was not examined until eight hours before her daughter’s birth, even though she had a high-risk pregnancy. The CQC’s director of operations, Helen Rawlings, comments that “all mothers have a right to safe care and treatment when having a baby… it is unacceptable that their safety was not well managed by Nottingham University Hospitals NHS Trust.”

Amy Fielding, a Leeds-based partner in the Clinical Negligence team at Stewarts, comments:

 “Regrettably, Nottingham University Hospitals NHS Trust is not alone in their recent failings to mothers and babies in the UK. As the need for a review such as the Ockenden Review suggests, the continued poor standards for maternity care being revealed throughout many areas of the country are not something to merely move on from, but to learn from and implement real life changing improvements. It is only then that the focus can shift onto sustaining these practices which can then lead to restoring real public confidence in maternity care. As one of the most critical areas of healthcare, mothers and families have the basic right to deliver babies in a safe and trusted environment.”

The Ockenden Maternity Review

The decision to fine NUH comes amid the ongoing review of maternity services, the largest maternity inquiry in NHS history. The Ockenden Maternity Review, headed by senior midwife Donna Ockenden, plans to improve the quality of care and safety across maternity services in the UK. Ms Ockenden aims to do so in a way that the improvements are sustained so that “local families and staff can once again have confidence and pride in the safety of their local maternity services”.

The review transpired because of significant concerns that were raised by local families about the quality and safety of the maternity services at NUH. Kim Errington was one parent who called for the independent review of the trust: her son Teddy died at NUH in 2020 when he was one day old. NUH failed to trigger the hypoglycaemia monitoring pathway, instead sending Teddy home. The next day he was blue lighted back to hospital, but passed away shortly after. Ms Errington said that the lack of trust in the system made her feel unsafe and questioning.

Responding to Nottingham Magistrates Court’s findings, NUH chief executive Anthony May commented that “the mothers and families of these babies 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… We fully accept the findings in court today and have already implemented changes to help prevent incidences like this from this happening again.”

It was recently announced that the Ockenden Review findings will be delayed to June 2026, as 300 more cases were recently discovered. The Review now totals over 2,500 families. In the meantime, the CQC will continue to monitor the trust to ensure that improvements are being made so that babies and their mothers are treated safely at NUH.

Paralegal Florence Rhodes contributed to this article.