Serious mistakes in the care of mothers and babies at a scandal-hit NHS hospital were kept hidden from regulators and senior health bosses.
A new inquiry into poor maternity care at Nottingham University Hospitals Trust, one of the largest in England, has now started its work and it will investigate how mistakes were incorrectly downgraded in a way that meant the trust avoided scrutiny.
This is thought to include baby deaths, stillbirths and children suffering brain damage during birth.
It meant incidents were not reported to NHS England or local health bosses and gave the impression there were fewer mistakes happening on the trust’s maternity wards compared to other hospitals.
The new inquiry comes after an investigation by The Independent and Channel 4 News earlier this year, which revealed dozens of babies had died or suffered brain damage at the trust over the past 10 years, with families accusing the hospital of covering up what happened to them.
The trust has been found liable for more than £91m in clinical negligence costs. These cases include 34 deaths and 46 cases of babies left with permanent brain damage.
At least 20 families have already been included in the new investigation, with NHS chiefs appealing for any other parents to come forward with concerns.
The inquiry will be led by an experienced NHS manager, Cathy Purt, along with consultant obstetrician Dr Teresa Kelly and consultant midwife Debbie Graham, who ran one of the original early investigations into poor care at the Shrewsbury and Telford Hospital Trust – now embroiled in the largest maternity scandal in NHS history.
One key line of enquiry will be the way the Nottingham trust graded serious incidents. These incidents are governed by national rules that ensure incidents are reported nationally and properly investigated.
But a review of incidents found the trust had developed its own internal process that used a sub-category known as a “higher level incidents”. The local Clinical Commissioning Group and NHS England have since learned incidents that should have been reported nationally were downgraded to higher level incidents and kept internal.
In its terms of reference, the inquiry, which has been commissioned by Nottinghamshire CCG and NHS England, acknowledged the “failure to learn from incidents and investigations” by the trust, adding it recognised the “the potential for a number of incidents, complaints and concerns in relation to maternity care that may not have been appropriately identified, reviewed or escalated”.
Jack Hawkins, whose daughter Harriet was stillborn after mistakes by staff, told The Independent he welcomed the new inquiry.
“We have been victim-blamed and not believed for so long and its created havoc in our lives. To finally be believed is reassuring but I don’t feel we can relax yet.”
Harriet’s death was not classed as a serious incident for 159 days. Jack, a former hospital consultant at Nottingham’s Queen’s Medical Centre, said the use of the higher level incident sub-category was “the work of an unsafe organisation”.
“It is a scam,” he said, adding: “It was more about hiding things. Serious incidents are reported nationally and they stand there as a mark against the hospital. The trust has touted its system as a positive, but it was about subverting the rules.
“If they have been hiding baby deaths and other incidents in maternity services, what else has been happening in other departments? This inquiry will reveal more cases, it is a multi-system failure.”
The new investigation will go back as far as 2006 and examine data and information on the maternity services and how they were run to identify trends and actions for improvement.
The inquiry team will examine the care of mothers and babies and if necessary refer some cases for separate focused independent investigations after concerns some have not been looked at. This will provide families with specific answers to their concerns.
In the case of baby Wynter Andrews, who died as a result of neglect in 2019, the trust wrongly claimed her death was “expected” and it was only when her parents raised the alarm that questions were asked.
Her mother, Sarah Andrews, said: “If I hadn’t asked questions, the coroner would not have investigated. It was a real concern for us that there would be other families who were allowed to slip through the net and don’t know that what happened to them was avoidable.”
She added that she was positive about the inquiry and the process for independent investigations of cases, but said: “Past recommendations they didn’t act on could have made a difference in Wynter’s case. The review itself is a positive thing but they failed to make changes in 2018 when their own staff were warning of safety concerns, so we are very sceptical they are going to make changes now.”
Announcing the start of the inquiry, NHS England and the CCG said they recognised “the maternity care provided by the trust has not been of the quality required, and that issues remain ongoing”.
As well as the trust, the investigation will also consider the actions of the Care Quality Commission, NHS England and the CCG.
It will consider stillbirths and neonatal deaths, as well as the deaths of mothers and babies who suffered serious injuries and general care on maternity wards.
Cathy Purt, who is leading the investigation, told The Independent: “We are grateful to all the families who have taken such an important role in establishing the review of maternity services in Nottingham, which is now underway. The first review team meetings have taken place.
“Throughout the review, we will share our findings with Nottingham University Hospitals so that changes can be made without delay whenever we identify weaknesses, but we want to emphasise that the review will be completely independent of the trust, and will provide transparent information to families as well as clear recommendations for service improvement.”
Families who have concerns about maternity care at Nottingham trust can contact the investigation team by emailing email@example.com.
The trust recognised it hasn’t always categorised incidents appropriately. It told The Independent that in early 2021 it changed its processes with the aim of ensuring the right level of investigation was carried out every time, so that it can provide families with the appropriate support and identify learning.
Chief nurse, Michelle Rhodes, said: “We are doing everything in our power to ensure that the families using our services get the best possible care and will fully co-operate with the independent review.”