Record NHS baby deaths fine 'follows empty promises'

The parents of a baby girl who died 23 minutes after being born under the care of an NHS trust have slammed the organisation for "empty promises" after watching it be prosecuted for the second time.

Wynter Andrews died in September 2019 under the care of Nottingham University Hospitals (NUH) NHS Trust, leading to the organisation being fined £800,000 in 2023.

On Wednesday, the trust was handed a record £1.6m fine - the largest ever for an NHS trust for maternity care - following another prosecution brought by the Care Quality Commission (CQC) over the deaths of babies Adele O'Sullivan, Kahlani Rawson and Quinn Parker in 2021.

After the sentencing, Wynter's parents Sarah and Gary said the case confirmed what they had said "all along - Wynter's death was not an isolated incident".

The trust remains at the centre of the largest maternity inquiry in the history of the NHS. The review began in 2022 and is looking into more than 2,000 cases dating back to 2012.

Mr and Mrs Andrews watched Wednesday's proceedings at Nottingham Magistrates' Court from the public gallery, as the families of Adele, Kahlani and Quinn heard the sentence being passed by District Judge Grace Leong.

In her remarks, the judge said: "There were similarities between the current cases and the failures concerning Baby Wynter namely, a lack of escalation of care, the inadequate communication systems and the failure to provide clear and complete information sharing."

These failings, the judge said, were among a "catalogue" of others that led to the babies and their mothers being exposed to significant risk of avoidable harm, and in Quinn's case, resulted in him suffering avoidable harm.

After Wynter's death in 2019, a CQC inspection of NUH in October 2020 led to the trust being placed in "special measures".

It was inspected again in April 2021 and a number of improvements had been identified, the court heard.

That inspection took place "either around the or after the death of baby Adele", and the report was published in May.

Baby Kahlani died in June, followed by the death of baby Quinn in July.

Separate inquests into their deaths highlighted a "series of errors" and "missed opportunities" in their care.

The judge added there was "no explanation on why, notwithstanding the number of guidelines to aid and assist the medical staff, the grave mistakes in the care and treatment of the mothers and their babies recurred".

During the inquest into baby Wynter's death in 2020, the coroner said she had received an anonymous later from midwives at NUH's maternity unit, addressed to trust bosses, warning of a "potential disaster" as a result of staffing issues.

That letter was dated 10 months before Wynter's death.

Mr Andrews said the trust had "failed to listen" to those whistleblowers, adding they had been promised the trust would do "everything in its power to ensure such a tragedy would never happen again".

He added: "We watched the proceedings of [Wednesday's] prosecutions from the public gallery as concerned parents - who were promised several years ago that our daughter's death would bring about change.

"It is apparent [now] that those entrusted to bring about change failed to do so."

While the maternity review - being led by senior midwife Donna Ockenden - is ongoing and now expected to reveal its findings in June 2026, the couple urged the Department of Health and Social Care to commission an independent, external investigation involving healthcare regulators.

They said: "The time for empty promises is over. The time to listen and learn is now."

Lawyers speaking on behalf of the families of Adele, Kahlani and Quinn also called for greater accountability and action.

Natalie Cosgrove, on behalf of Quinn's parents Emmie Studencki and Ryan Parker, said: "The medical expert confirmed that had the trust taken just one of many opportunities to provide suitable care, then Quinn would be sitting down for his afternoon snack at nursery right now.

"Instead, he is buried in the ground."

Sadie Simpson, speaking on behalf of the parents of Adele and Kahlani, added: "Whilst it is accepted that some changes have been made, for years, families and staff have raised alarm bells about the quality of care at NUH, and tragically, the consequences have been devastating.

"This case reinforces the urgent need for meaningful and lasting improvements, and the time to act is now."

Following the hearing, NUH chief executive Anthony May said: "The mothers and families of these babies have had to endure things that no family should after the care provided by our hospitals failed them, and for that I am truly sorry.

"Today's judgement is against the trust, and I also apologise to staff who we let down when it came to providing the right environment and processes to enable them to do their jobs safely."

The trust added it had made a number of changes through its Maternity Improvement Programme, including increasing staff numbers and launching a new foetal medicine unit and neonatal unit.

"There is more to do, but we know we are on the right path to improvement," Mr May added.