Legal Update
Nottingham University Hospitals NHS Trust (City Hospital and Queen’s Medical Centre) – Donna Ockenden’s Maternity investigation is under way
6 December 2022

Nottingham University Hospitals NHS Trust (City Hospital and Queen’s Medical Centre) – Donna Ockenden’s Maternity investigation is under way

Author: Kate Clarkson

Donna Ockenden’s investigation into Nottingham University Hospitals NHS Trust has begun, with the aim of making sure ‘the performance at the trust’s maternity service improves as quickly as possible, and in a way that means those improvements are sustained.’ The report will assess ‘whether cases of concern were adequately investigated by the Trust at the time, if the lessons for learning were appropriate ones, and whether the lessons were indeed learned and acted upon.’

In 2021 it was identified that dozens of grieving families at Nottingham’s City Hospital and Queen’s Medical Centre, had been told that catastrophic maternity care failings leading to death and significant injuries were ‘one offs’.

Investigations by The Independent and Channel 4 suggested a pattern of poor care, inquiries that were delayed and that minimised concerns, and a failure to make changes that could have kept mothers and their newborns safe. The Independent has reported that in some cases notes were missing or never made, and in other cases they were inaccurate.

It is suggested that the Trust has known for some time that the standard of care was not acceptable within the hospitals.

In 2018, the Trust’s board was sent a letter from doctors and midwives working across its two sites, saying that a lack of staff in its maternity units was endangering patient safety.

In 2020 the Care Quality Commission identified ‘several serious concerns’ including poor risk management which they said threatened the safety of mothers and babies. Maternity care was rated as inadequate. 

Figures obtained by the BBC found that between 2005-6 and 2020-21 there were 207 claims against the Trust’s maternity services, including 36 for cerebral palsy, 26 for stillbirths and 24 for brain damage. In excess of £110m in damages was awarded over that period.

In April 2022 a thematic report was published, commissioned by the local Clinical Commissioning Group (CQC) and NHS England. It was roundly criticised as being too narrow and not independent enough.

In May 2022 CQC inspectors returned to find some improvements, although stated that further improvements were needed to ensure that the Trust comprehensively manages risks to all people’s safety. Concerns were raised about triage services and an increase in stillbirths.

Donna Ockenden, who has previously led the investigations at Shrewsbury and Telford NHS Trust was appointed in May 2022 to lead the Nottingham investigation. By November 2022 over 700 families and 250 staff members had got in touch.

The Trust has now recognised that more than 1,000 families may have a relevant case for review. Those families have been contacted by the Trust, and others who may have a relevant case are urged to come forward. These are cited as cases from the last 5 years in the following 5 categories:

  1. Still births;
  2. Neonatal deaths from 24 weeks gestation that occur up to 28 days of life. The review will also consider neonatal serious incident reports and neonatal never events;
  3. Babies diagnosed with Hypoxic Ischemic Encephalopathy (Grades 2 and 3) and other significant hypoxic injuries;
  4. Maternal death up to 42 days postpartum; and
  5. Severe maternal harm, to include all unexpected admissions to ITU requiring ventilation, major obstetric haemorrhage, peri-partum hysterectomy and other major surgical procedures arising from the maternity episode, eclampsia and clinically significant cases of pulmonary embolus requiring further treatment. 

For some of these families, it is claimed that the letters from the Trust were the first time they had been notified that they may have received poor care.

The Trust has stated that it is committed to making necessary and sustainable changes to ensure the safety of women and babies going forward. It is hoped that the report will sit alongside the already published reports from other Trusts and contribute further evidence and recommendations to ensure safety within maternity services nationwide.

The Healthcare Safety Investigation Branch stated that 760 investigations took place in the year to March 2021 involving incidents at 125 NHS Trusts. Their findings highlighted concerns in respect of communication, poor clinical record keeping, a failure to ensure consultant oversight of care in high-risk cases and a vast quantity of guidance produced at a national and local level for midwives that was at times unclear and conflicting.

It is clear now that maternity services across the nation are under intensive scrutiny. Whether Nottingham is the last to undergo independent investigation remains to be seen. What is clear is that the guidance that will come out of the reports will be extremely important in ensuring future care for pregnant women and their babies is safe and consistent.

So, what does this mean for us as lawyers? Whilst the outcome of the enquiry is yet to be determined, it will make for essential reading for representatives for both claimant and defendant. It is hoped that this report will chime with those already published (Shrewsbury, Morcambe) and clearly articulate what the standard of care should have been and give examples of where care fell short. For claimant practitioners this will be invaluable. The analysis of guidance available for midwives and obstetric staff, particularly where this has been contradictory may give rise to further lines of enquiry when making a claim. For defendants this may be crucial to assist in assessing risk and identifying those cases in which early settlement may be appropriate.

The Ockenden report into maternity services in Nottingham University Hospitals NHS Trust is expected to be published in March 2024.

To contact the review team, email or telephone 01243 786 993.