A couple whose newborn baby died after a ‘long list of failings’ by the NHS called for a public inquiry yesterday as the trust was fined £1.6m.
Nottingham University Hospitals (NUH) NHS Trust was handed the penalty by a district judge after it admitted failing to provide safe care and treatment at a maternity unit where three babies died.
Quinn Parker, Adele O’Sullivan and Kahlani Rawson all died at Nottingham City Hospital within a 14-week period in 2021.
After hearing District Judge Grace Leong condemn a series of ‘avoidable’ failures which led to the deaths, Quinn’s parents said although their son ‘never spoke, he has a voice, and it has been heard’.
In a statement read on Emmie Studencki and Ryan Parker’s behalf outside court, their lawyer Natalie Cosgrove said: ‘Quinn died from a long list of failings and Emmie’s life was put at risk.
‘Some failings so basic, that a passing stranger on the street would have provided better attention to, and quality of care.
‘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.’
They said Quinn was starved of oxygen before he was delivered by emergency Caesarean section and fought for life for 36 hours in an unsuccessful attempt to ‘recover from the harm inflicted on him’.
Emmie Studencki (pictured left) and partner Ryan Parker (pictured right) told a court they had been left with severe post-traumatic stress disorder and depression after the loss of their son Quinn at Nottingham City Hospital, part of the troubled Nottingham University Hospitals (NUH) NHS Trust
Quinn Lias Parker died on July 16 , 2021, just two days after he was born at City Hospital in Nottingham
NUH is currently at the centre of the largest ever inquiry into NHS maternity care, was charged with five counts of failing to provide adequate care, exposing the babies or their mothers to a risk of serious harm, and a sixth related to harm caused to Quinn – with a barrister entering guilty pleas on its behalf on Monday.
The trust is the first to be prosecuted by healthcare watchdog the Care Quality Commission (CQC) more than once. It was fined £800,000 in 2023 for failures in the care of Wynter Andrews, who died 23 minutes after being born at the Queen’s Medical Centre in Nottingham in September 2019.
The CQC says the trust did not ensure safe care and treatment due to a lack of adequate systems and processes being in place or not being appropriately implemented to ensure staff managed all risks to mothers and babies’ health and wellbeing.
When the case returned to Nottingham Magistrates’ Court for sentencing today, DJ Leong said expectant mothers ‘should be able to give their trust to doctors, nurses and midwives and be assured their babies will be safely delivered.’
Referring to the families Quinn, Adele and Kahlani, who were sat in court throughout the hearing, the judge added: ‘The death of a child is a tragedy beyond words, and when that loss is avoidable the pain is even more profound.’
She said parents had ‘placed their trust in a system that was meant to protect expectant mothers and keep their babies safe, and that trust was broken’.
Nottingham University Hospitals (NUH) NHS Trust was handed the penalty by a district judge after it admitted failing to provide safe care and treatment at a maternity unit where three babies died
When the case returned to Nottingham Magistrates’ Court (above) for sentencing today, District Judge Leong said expectant mothers ‘should be able to give their trust to doctors, nurses and midwives and be assured their babies will be safely delivered’
The judge said that the parents’ grief was ‘not just about the past, but about the future’, describing a ‘lifetime of missing first words, first steps, first days at school, and memories that should have been made’.
The trust has an average turnover of £612 million, but DJ Leong said she was ‘acutely aware’ that all its funds as a publicly funded body were accounted for and that the trust is currently operating at a deficit of around £100 million, but added that a financial penalty had to ‘mark the gravity of these offences’.
The court was told failings in some or all of the deaths included a failure to enact the trust’s own policies and procedures, inadequate Cardiotocography (CTG) monitoring, workload pressures, a failure to expediate delivery of the babies and a failure to identify placental abruption taking place. Reviews of the deaths found that these failures represented a failure to provide safe care.
Bernard Thorogood, for NUH, claimed numerous improvements had since taken place.
‘Staff are better informed, systems are better, training is better’ and the number of midwives had been ‘very substantially increased’, he said.
The trust’s latest CQC inspection, in 2023, found it required improvement.
Independent midwife Donna Ockenden is leading an investigation into more than 2,000 cases of maternity care at the trust over a ten-year period between 2012 and 2022. The probe is looking at cases where either a baby or mother died or suffered severe harm – with around four taking place each week.
In November, Nottinghamshire police said ‘more than 100’ of the cases it had examined had been referred for potential criminal investigation.
