Avoidable Baby deaths reported at Nottingham University hospitals NHS Trust

01 July 2021

Following an investigation jointly undertaken by The Independent and Channel 4 News, repeated examples of poor maternity care have sadly been uncovered at Nottingham University hospitals NHS Trust.

Worryingly, the investigation found repeated examples of poor care over the past decade. Sadly, some families who participated in the investigation commented that tragedies could have been avoided, if earlier errors had been taken more seriously. The investigation revealed numerous flaws in the service including inaccuracies in maternity medical records and a delay in investigation of baby deaths.  It also found examples of inaccurate or ‘watered down’ information included by the trust in internal investigations, when they were undertaken.

 The trust provides maternity care to approximately 10,000 women every year. In December 2020, the Care Quality Commission (CQC) rated the trust’s maternity care as “inadequate”.  This was based on a series of failures identified in the risk assessment procedures implemented by the trust in addition to inadequate reporting of heart traces for babies, tragically leading to harm or death as a result. 

 An unannounced visit was made by the CQC in May 2021. The CQC have reported some improvements but with further changes still needed. The service remains rated as “inadequate”. The Trust have themselves commented;

 “We are working closely with the CQC, our partners and local Maternity Voices Partnership to ensure that we have done - and we are continuing to do – everything we can to make rapid improvements to maternity care and to learn the lessons from past failures.”

In the past few weeks, it has been reported that a number of maternity wards have been downgraded to “inadequate”, with Northwick Park Hospital, East Suffolk, Sheffield Teaching Hospital NHS Foundation Trust and North Essex Foundation Trust all included in recent inspections from the CQC.

Sharon Banga a specialist clinical negligence solicitor based in Shoosmiths Birmingham medical negligence team comments:

‘The findings of this investigation and those of the CQC previously, particularly relating to death and serious injury to babies, need to be taken seriously, investigated and lessons should be learned.  This does not appear to be happening at present by many trusts nationally, as is evidenced by the number of maternity units that have recently been downgraded by the CQC. Sadly, through the many clients that we represent that have suffered maternity failures, we often see the tragic consequences for the families that have suffered the effects."  

Sharon continued:

“The safety of patients is a priority.  When mistakes occur, a trust must be willing to fully investigate with transparency and implement change where needed.  Our experience, especially in light of the findings of the recent BBC Panorama investigation into the failure of trusts to always share the reports conducted by reviewing bodies with the regulators, is that changes are needed to uphold public confidence in the health service and so that lessons can be learnt when mistakes sadly happen.  It’s clear in this situation that there is much to be done by the trust to improve maternity patient safety in line with the recommendations made by Donna Ockenden in her interim report in December 2020.’ 

Sarah Harper, clinical negligence specialist and Legal Director in our Northampton office, together with the Shoosmiths Serious Injury team, continue to support Sarah’s previous client with Campaign for Safer Births, a charity set up to reduce the avoidable deaths of babies and mothers during birth.  




This information is for educational purposes only and does not constitute legal advice. It is recommended that specific professional advice is sought before acting on any of the information given. © Shoosmiths LLP 2024

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