Six deaths of women due to poor care, and hundreds of other cases of potentially avoidable harm to mothers and their babies happened over 13 years at Nottingham University Hospitals, a major inquiry has found.
There were multiple causes, including midwives ignoring women’s concerns, failing to do basic safety checks during labour and delays in carrying out crucial interventions like Caesarean sections.
These were compounded by understaffing that left wards in “crisis mode”, constant management turnover and a “toxic” workplace culture of bullying and cliques, where mistakes got covered up rather than lessons learned, concludes the report. It was led by Donna Ockenden, a midwife and safety investigator, after a three-year investigation involving more than 2,500 families.
The review into maternity care at the trust, released today, is the latest inquiry in a series of safety scandals where women giving birth received substandard NHS care.
It echoes similar findings from inquiries into maternity scandals at Furness General Hospital in Morecambe Bay in 2015 and Shrewsbury and Telford Hospital in 2022.
These were some of the most disturbing findings about Nottingham.
Women were told to stay away from hospital for too long
The midwives at Nottingham routinely persuaded women in labour to stay at home for as long as possible in the hope of achieving “normal” births without medical interventions, according to the report.
While it is standard to discourage women from coming to hospital when unnecessary, at Nottingham this was too extreme, the report found. “There was a culture of not admitting women who were seeking admission in labour,” it said.
Combined with failures to do safety checks, like vaginal examinations and listening to the baby’s heart, this led to many cases of avoidable harm. “We did send women home in the [early] phase of labour, often without risk assessment, so there were missed opportunities,” said one staff member.
This happened with the Hawkins family, whose baby Harriet died during birth in 2016. Sarah Hawkins laboured at home for six days, despite multiple phone calls and visits to the hospital. “We had gone to the experts and they had said, ‘Calm down, you’re fine’,” said her husband, Jack.
When Sarah was allowed to come to hospital, she should have been rushed into theatre for an emergency C-section, but care was delayed and she was eventually stillborn. The Hawkins’ experience became the catalyst for the inquiry, and there were found to have been 13 failures in their care. “Her death was avoidable and was due to the poor care her mother Sarah received,” said the report.
Mistakes were covered up, not learned from
When mothers or babies come to harm, hospitals should investigate to find out if there was anything they should be doing differently. But senior doctors at Nottingham covered up some mistakes, refusing to class them as “serious incidents” that needed formal investigation, the report found.
“Obstetricians would decide whether to investigate and more often than not, would close the thing down,” said a doctor who was part of the investigation team and left the hospital for this reason. “Clinical incidents were brushed under the carpet.”
Felicity Benyon experienced this in 2015 after her bladder was removed by mistake when she was supposed to be having a C-section and her womb removed because of a medical condition.
Benyon was initially told the bladder was taken out deliberately because it was damaged by the medical condition. An independent investigation showed this was not true. Benyon now has to wear a pouch to drain her urine into, which must be emptied several times a day.
Senior management at the hospital had been warned of safety problems since 2010. This “should have prompted earlier and more decisive intervention,” said Ockenden.
Denial of pain relief and cruel comments
Many women reported delays in being given pain relief and sometimes its complete denial. “I was sneered at for asking for pain relief,” said one woman.
“I begged for an epidural… I was told it was coming but it never did,” said another.
A significant number of women said they had received unkind or dismissive comments from staff, the report found. “Midwives detailed entrenched ways of behaving that were unprofessional and cruel to women,” it said.
At night, lead midwives did shopping on the internet, while junior staff cared for two or three women each, one staff member told Ockenden.
Bodies of babies were treated poorly
Failings have also been found at the hospital mortuary. Sometimes bodies were allowed to decompose, instead of being transferred from the fridge to the freezer after 30 days, as required.
One early-gestation baby was disposed of as clinical waste. Another family unexpectedly received graphic, colour photographs of their baby’s post mortem examination, along with a breakdown of costs.
Lessons need to be learned
Ockenden said the report must not become another “document on a shelf”, but must be the catalyst for safer care and lasting improvement. “We owe it to those whose lives have been forever changed to ensure that lessons are learned, improvements are delivered,” she said.
Anthony May, chief executive of Nottingham University Hospitals said in May he would oversee the trust’s improvement programme for the next two years.
Health Secretary James Murray said: “We will reflect on these findings and lessons from Nottingham will form part of our national plan to deliver real improvements in maternal and neonatal care for all families.”
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