Nottingham University Hospitals NHS Trust put Wynter Andrews and her mother Sarah Andrews at “significant risk of avoidable harm” for being understaffed and failing to ensure staff at Queen’s Medical Centre, according to a prosecutor nottingham was aware of his own policies, culminating in Wynter’s death on September 15, 2019.
The baby died 23 minutes and 30 seconds after birth via emergency caesarean section in the arms of her mother and father Gary Andrews.
At a hearing before Nottingham Magistrates’ Court on Wednesday, the Trust pleaded guilty to two counts of being a registered person for failing to provide care and treatment in a safe manner, resulting in damage or loss.
Ms Andrews said in court alongside the family’s lawyer: “As first-time parents, all we ever wanted was to bring our precious baby home.
“The trust’s management have received repeated warnings from staff about safety at the unit, but they have taken no action. They were repeatedly warned by bereaved families and injured families, but they didn’t listen and didn’t learn.
“They have been repeatedly notified by various investigative agencies over many years of maternity safety concerns at the Trust, but they have failed to make the critical changes needed.
“We hope that this prosecution of the trust for its unsafe care is finally the nudge needed to prioritize patient safety and lead to meaningful change.”
Ryan Donoghue, prosecutor, outlined several “serious” and “persistent” deficiencies in the care given to Ms Andrews, which were exacerbated by staff shortages, which resulted in the midwife caring for her also having a patient in another ward had to look after.
Ms Andrews was hospitalized on September 14, her due date, after an “uncomplicated” pregnancy.
A labor contraction scheduled for September 7 was called off at Ms Andrews’ request, but a later inquiry found that this was given the blessing of a midwife without consulting an obstetrician, and the decision had limited justification in the medical records.
When Ms Andrews was in labour, doctors described Wynter’s heartbeat as ‘suspicious’ and at 1.33pm on September 15 it was decided that she should be delivered by caesarean section.
After complications during the operation, she was discharged at 2:05 p.m. in “poor” condition and later died.
Mr Donoghue told the court that the Trust “failed to ensure staff were adequately informed and trained in relation to the care of expectant mothers and the birth of babies, including physical checks, consultation with older colleagues and prescription of medicines “.
The CQC, which oversees and inspects health services in England, said last July it would prosecute the trust.
Bernard Thorogood mitigatingly told the court that since the CQC and the Health Care Safety Investigations Division began investigating the case, the Trust has made full and candid admissions about the shortcomings.
Mr Thorogood added that “the heart of the Trust was in the right place” and that the Trust is responsible for around 8,000 births a year, often without incident, and that staff shortages are not unique to the Trust.
He said: “We accept that training hasn’t always been what it should have been.
“There were guidelines and well motivated, well trained staff, not always as well trained as they should have been and not always in sufficient numbers at the time, but these are the ingredients for a system that could work very safely.
“That wasn’t the case here, and that’s a sadness I can’t put into words.
“But it sure could work, and it sure had worked.”
The maternity ward at the QMC was rated as inadequate by the CQC, while the hospital overall was rated as in need of improvement when the site was inspected last March.
After the hearing, Anthony May, the Trust’s chief executive said: “We are truly sorry for the pain and grief we have caused Mr and Mrs Andrews due to deficiencies in the maternity care we are providing.
“We let her down at a joyous time in her life.
“Today we pleaded guilty and will fully accept the court’s findings.
“While words will never be enough, I can assure our communities that the staff at NUH are committed to providing quality care every day and we are working hard to make the necessary improvements needed for our local communities, including full and open engagement with Donna Ockenden and her team in their ongoing independent review of our maternity services.”
District Judge Grace Leong told the court that she will deliver a verdict at 10 a.m. Friday, which could at most be an indefinite fine.