The long-awaited report into maternity failures at Nottingham University Hospitals NHS trust (NUH), the largest investigation of its kind involving about 2,500 families, will be published later this week.
Led by the senior midwife Donna Ockenden, the inquiry investigated stillbirths, neonatal deaths, maternal deaths and babies or mothers who suffered brain damage and other injuries between 2012 and 2025.
It follows a decade-long campaign for justice and change by the families affected. Some share their stories about what happened to them in Nottingham, and explain why this is such a landmark moment.
Wynter Andrews
Wynter died in 2019 at the Queen’s Medical Centre (QMC) from hypoxic ischaemic encephalopathy – a loss of oxygen flow to the brain – which could have been prevented had staff delivered her earlier.
Wynter’s mother, Sarah Andrews, said: “I went into labour and I was having contractions, and for six days, I was basically told to stay at home. I didn’t feel like I had any other choice. And then in hospital, the care was just beset by failures.
“I actually said to my husband I felt like I’d be better off dead than in the situation I was in … It was truly horrific. When they eventually called the emergency C-section and opened me up, the smell of infection filled the room and that’s when they realised that Wynter was stuck in my pelvis. All the warning signs of infection were there.
“Me and Gary had to watch for 23 minutes while they failed to resuscitate her. We had staff come visit us in the bereavement suite and they said it was one of those things, that sometimes babies die. One said to us: ‘If we listen to every mother’s concerns, we’d be overrun.’ They’re telling us that they can’t see anything that’s gone wrong. And a year later, at the inquest, the coroner rules that it’s a clear and obvious case of neglect.
“We have a lifetime of growing up without our daughter. When the cameras stop rolling, when the media goes home, we’re still traumatised people. We continue to live this every day. We’ll never be the same people we were before.
“This report is going to be very traumatic for families but I think it’s important that what happened in Nottingham is laid out so that we can ensure those failures aren’t repeated again.”
Felicity Benyon
Felicity had an emergency hysterectomy at QMC after giving birth in 2015 when she was 29, during which medics accidentally removed her bladder, leaving her with a urostomy bag.
Felicity said: “I had a difficult pregnancy, I was in hospital for weeks. I had a planned C-section and was told that since it was such a high-risk case, a multi-disciplinary team would be involved. But that never happened. They actually let a student doctor do it, despite it being the highest risk C-section they’d had in years. They took out my bladder without even realising. The whole thing.
“Originally they said the placenta accreta [a serious pregnancy condition where the placenta attaches too deeply into the uterine wall] had completely enveloped the bladder. Initially, I was just so happy my baby was alive, so happy that I’d survived because they made me think they had saved the day.
“But then they instigated an investigation, which found the accreta had not touched the bladder and it was completely healthy. I was absolutely floored. It should have just been a hysterectomy and then home, instead of living with lifelong complications.
“It’s completely taken my trust away. I have regular hospital appointments because I now live with this disability, and it’s horrific because I don’t feel like I can trust doctors. I don’t feel safe in hospitals. But that’s the place you’re supposed to feel safe because it’s where you’re at your most vulnerable.
“This review is a huge moment because we’ve fought for years to get this. Going into a pregnancy there’s a risk, but we’re talking about things that were preventable. Things that should never have happened. Things where there’s actually already a system in place to stop them from happening, but it’s just not being adhered to.”
Caitlin Stringer
Caitlin was born prematurely in 2021 at Nottingham City hospital and at 30 daysdeveloped necrotising enterocolitis (NEC), a severe, life-threatening gastrointestinal emergency. Her parents allege the failure of staff to treat her quickly led her to collapse and suffer a severe brain injury.
Caitlin’s mother, Emily Stringer, said: “Caitlin did really well initially, and got off the ventilator really quickly. But we’d been having concerns for few days. We’d been taking photos and showing them to staff of Caitlin’s abdomen getting bigger and bigger, and she wasn’t tolerating her feeds. She was struggling with her breathing and becoming increasingly lethargic. These are all red flag signs of NEC.
“But staff had an answer for everything. They addressed all of our concerns in isolation. No one was either able or willing to join the big picture together, take a step back and think, no, these parents are right, this is a deteriorating baby.
“She collapsed and needed to be put on to a ventilator. The next day her condition worsened. She ended up having over half of her bowel removed because it had ruptured and died inside of her. About a month later, she had a brain scan which showed a devastating injury.
“The trust commissioned an external review and found an X-ray had been taken about 15 hours before Caitlin collapsed, which diagnosed NEC, and she should have been given antibiotics within an hour – but she wasn’t.
“Now she’s expected to die in childhood. She has cerebral palsy and has had multiple respiratory arrests at home. She was in paediatric intensive care 13 times last year. We know that one day one of these will be fatal. It’s horrendous.
“This review feels like the validation that I never wanted. It’s great that people will understand the truth, the scale of what’s happened to thousands of families in Nottingham, but heartbreaking that they have to. Things that you think are unthinkable, that you think are ludicrous, they can’t possibly do that – well, we know that they have.”
Quinn Parker
Quinn died at Nottingham City hospital 36 hours after his birth in 2021. His mother, Emmie Studencki, went to hospital four times with bleeding in the late stages of her pregnancy and said her requests for a caesarean section were ignored.
Quinn’s father, Ryan Parker, said: “I know it’s very cliche, but you do think you’re in the best place at the time. Emmie had bled a lot, and in hospital we had a feeling that something wasn’t right. What is really happening is Quinn is just slowly dying but no one’s doing anything.
“Eventually a doctor decided to break her waters and I just remember the whole bed was covered in blood and liquid. People came flying in and tried to scan for Quinn’s heart, and Emmie was stretchered out. I didn’t know if either of them were alive. Eventually a midwife told me that Quinn was OK and Emmie was in recovery, but then 90 minutes later a neonatal consultant appeared and told me Quinn actually had brain damage.
“We later found out that paramedics had noted all of the concerns about rigid abdomen and blood loss of over a litre, and the notes were not collected properly by the hospital.
“The Ockenden review doesn’t feel like the end of a journey, it feels like a significant landmark moment which should result in more attention and a fundamental appreciation of how dire some maternity care in this country is. Ultimately you want to ensure other places aren’t a Nottingham, but the reality of the situation is other places are already Nottinghams.”
Harriet Hawkins
Harriet was stillborn at Nottingham City hospital in April 2016 after her mother had been in labour for six days. An external review of the case found 13 failures and concluded the death was almost certainly preventable.
Her mother, Sarah Hawkins, said: “You hope that you’re going to be the only person that’s been through this, but when you hear of other people, and it’s not just one or two, it’s hundreds and thousands. You just lose your faith in the NHS.
“When I was eventually brought in, Harriet’s head was coming out of me. For three years, they tried to tell us it was an infection. We had to wait two years to have Harriet’s funeral.
“For so long in Nottingham we were made to feel like the mad grieving parents. Harriet should have been a serious incident within 48 hours, and it took us 159 days to actually get an incident logged. It just felt like a complete cover-up.
“Quite a lot of people focus on statistics, and that’s fine. But you’ve got to think we drove home with an empty car seat, we had to empty our nursery, I gave birth so I still had leaky boobs and hair loss, you have everything. It’s not just an intrapartum death, it’s someone’s baby.
“The massive thing for me [with the Ockenden report] will be the feeling of eventually being heard and listened to. It took over 10 years. Loads and loads of families were referred to as tragic, isolated cases which clearly wasn’t the case.”
The NUH chief executive, Anthony May, said: “I want to pay tribute to the bravery of the many families who have worked tirelessly to get answers and to make maternity services safer for others.
“I have met some of the affected families, and they have shared their painful and life-changing experiences with me, for which I am very grateful. I am very sorry for the pain and suffering these families have endured.”
He said NUH staff had “shown their commitment to change”.
“Upon receiving the findings of the review, we will consider carefully what we need to do next to ensure that we learn from what happened in the past and to continue to improve maternity services,” he said.
Source:
www.theguardian.com
