Care Quality Commission
CQC prosecutes Nottingham University Hospitals NHS Trust after it failed to provide safe care and treatment to a mother and baby
Nottingham University Hospitals Trust has been fined £800,000 after pleading guilty to two offences of failing to provide safe care and treatment to a mother and her baby, exposing them to a significant risk of avoidable harm, following a sentencing hearing at Nottingham Magistrates’ Court.
CQC has prosecuted the trust after mistakes it admitted meant a mother, Sarah Andrews, and her baby, Wynter Andrews, did not receive safe care and treatment in its maternity services.
Wynter died shortly after her birth in September 2019 at the trust’s Queens Medical Centre in Nottingham.
CQC’s prosecution consists of two charges to which the trust has pleaded guilty. The first is for its failures in Sarah’s care, the other is for its failures in Wynter’s care.
The trust admitted it did not provide safe care and treatment for Sarah and Wynter, in that it failed to ensure that adequate processes and systems were in place and implemented to ensure that all risks to their health and wellbeing were appropriately managed. This exposed Sarah and Wynter to a significant risk of avoidable harm.
Sarah, aged 33, was deemed as having a high-risk pregnancy due to several health factors.
An investigation found multiple failings and missed opportunities in Sarah’s care from when she attended the Queen’s Medical Centre during her pregnancy, right up to the birth of her baby at 40 weeks.
In pleading guilty to the offence, the trust admitted several failures in the care of Sarah and Wynter arising from various underlying failures in terms of its systems and processes. Key failures took place from 40 weeks onwards, when Sarah presented as contracting and was found to be 4cm dilated.
The failures in care included:
- When Sarah presented to the Queen’s Medical Centre at 37+1 weeks for further investigations due to concerns with abdominal pain, there was insufficient indication for the induction of labour on 7 September. It was not mandatory to proceed with this approach and no underlying reasons for the decision were recorded
- When Sarah spoke to her community midwife and stated she did not wish to go ahead with the induction of labour on 7 September, there was no evidence of this change in plan being discussed with the obstetrics team, who ought to have had input into this and the timing of delivery
- When Sarah was admitted to the midwifery unit on 14 September, her blood pressure readings ought to have been interpreted as mild hypertension, in accordance with NICE (National Institute for Health and Care Excellence) guidelines. That ought to have led to an obstetrics review and guidelines would have specified that Sarah should have been transferred to obstetric-led care, with continuous monitoring of the baby’s heart rate. Local guidance stated that this transfer to obstetric-led care should have occurred within 30 minutes upon review
- Diamorphine was administered to Sarah on two occasions without a proper process being undertaken prior to prescription
- The CTG readings for Sarah and Wynter Andrews on 15 September ought to have been identified by at least 12:35pm. The findings of the readings ought to have triggered an emergency caesarean section, with delivery within 60 minutes (i.e. by 1:35pm). Delivery of baby Wynter did not actually take place until 2:05pm and Wynter sadly died in her parents’ arms 23 minutes after she was born by Caesarean section.
The trust admitted that underlying failures, in relation to its systems and processes in place at the time, led to the failures in the delivery of care to Wynter and Sarah Andrews which exposed them to a significant risk of avoidable harm.
In addition to the fine, the court ordered the trust to pay a £181 victim surcharge as well as £13,668.75 costs to the Care Quality Commission (CQC), which prosecuted these criminal offences.
The size of the fine is a decision made by the court and is informed by sentencing guidelines. The fine was reduced from £1.2m due to the trust’s early guilty pleas. CQC does not have influence over this decision.
Lorraine Tedeschini, CQC’s director of operations in the midlands, said:
“The death of Wynter Andrews is an absolute tragedy and my thoughts are with her family and all those grieving their loss.
“Mothers have a right to safe care and treatment when having a baby, so it is unacceptable that their safety was not well managed by the trust.
“The vast majority of people receive good care when they attend hospital, but whenever a provider puts people in its care at risk of harm, we take action to hold it to account and protect people.
“I hope this prosecution reminds care providers they must always take all reasonable steps to ensure people’s safety, including responding appropriately when our inspections identify areas needing improvement.”
Following Wynter’s death, the trust has worked to address these failings. It has also been closely monitored by CQC to ensure mothers and babies are safe in its care. An independent review is also being carried out by Donna Ockenden into failings at the trust’s maternity services.
Notes to editors
CQC brought this prosecution under regulations 12 and 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Regulation 12 covers healthcare providers’ responsibilities to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm.
Regulation 22 made it a criminal offence to not comply with regulation 12.
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