Parents have spoken out after biggest maternity inquiry in NHS history finds 520 mums and babies suffered harm or death at Nottingham hospitals linked to poor care
Grieving families have told how they “never wanted to be campaigners” after a landmark report exposed how hundreds of mothers and babies were harmed by the NHS.
At a press conference on Wednesday, many parents once again relived the worst moment of their life in the hope of preventing it happening to others. Top midwife Donna Ockenden’s inquiry into Nottingham University Hospitals NHS Trust (NUH) is the biggest of its kind in NHS history and found 520 mothers and babies suffered potentially avoidable harm or death due to poor care.
Around 2,500 families agreed to take part with around 2,000 consenting to be interviewed about events which in many cases have shaped their lives. They said they are “victims who became campaigners” because maternity staff and leaders failed to listen.
Many are now demanding a full statutory public inquiry. Here are some of their stories.
‘We knew the system – the cover-up was horrific’
When senior physiotherapist Sarah Hawkins and her hospital consultant husband Jack were expecting their first child, Harriet, they were both working at NUH and trusted their colleagues would look after them.
As her labour stretched on for days in 2016, the couple made 10 calls to the maternity unit and visited twice – but they were repeatedly told to stay at home and relax despite raising concerns that Mrs Hawkins couldn’t feel the baby moving.
When she was eventually admitted in her sixth day of labour, midwives struggled to find Harriet’s heartbeat and a scan revealed she had died.
The trust initially told the couple their daughter had died due to an infection but Dr Hawkins – an infections expert – was sure there was no sign of this. An external inquiry eventually found 13 failings in the care provided and said Harriet’s death was “almost certainly preventable”.
Sarah said: “After Harriet died – the cover-up was horrific, we knew this because we knew the system.”
Dr Hawkins said it is “appalling” that some staff at the trust chose not to participate in Donna Ockenden’s review.
Directly addressing former NUH colleagues during the affected families’ press conference, Mr Hawkins said: “We recognise that some of you have been expected to work in a constant state of crisis within a culture where bullying, intimidation and the fear of speaking up … too often felt normal.”
He added: “The fact that a significant number of senior staff chose not to participate in this review is appalling. You have demonstrated that maternity safety doesn’t matter to you, that self-preservation does.
“It shouldn’t have taken us as harmed and bereaved families to campaign for years and years, a decade, to be able to get some answers. And now we need accountability. And that’s why we need the public inquiry.”
Sarah added: “They need to be compelled to give evidence. Those clinicians, are they clinically safe if they don’t have patient safety at their heart?”
‘If you’d listened, hundreds of babies would still be alive’
Gary and Sarah Andrews, whose daughter Wynter died in 2019 some 23 minutes after being born,
NUH was fined £800,000 in 2023 after admitting failings in Wynter’s care in a criminal prosecution brought by healthcare regulator the Care Quality Commission (CQC).
A “catalogue of failings” exposed Wynter and her mum Sarah Andrews to a “significant risk of harm”.
Wynter died from a loss of oxygen flow to her brain which could have been prevented had staff delivered her earlier.
Gary, 38, told the press briefing that they were failed by NUH, which was fined £800,000 after admitting errors in the care of baby Wynter.
Addressing the trust directly, Gary said: “If you’d listened to concerns, there would be hundreds of babies still alive.
“Wynter would still be here – and her brother would not be looking at a gravestone.”
Sarah spoke of the experience of finding other campaigning families, saying it is “a club that nobody wants to be in”, but held back tears before adding she “couldn’t think of better people to be in it with”.
‘We were advised to terminate our healthy baby due to testing error’
The report referenced the heartbreaking case of Carly Wesson and her partner Carl Everson who terminated their pregnancy at 14 weeks.
Ms Wesson, 43, and Mr Everson, 47, were expecting their first baby which they had nicknamed “Ladybird” before wrongly being told the foetus had a rare genetic condition called Patau’s Syndrome, which often results in miscarriage, stillbirth, or the baby dying shortly after birth.
They were advised to consider termination by a foetal care consultant who said Ladybird would be left with severe care needs and might not survive the pregnancy.
They went ahead with termination after making “the most impossible choice we’ve ever had to make”. Investigations by the trust later showed that Ladybird had been a healthy baby.
The Ockenden report said: “For Carly and Carl, the weight of their loss is inseparable from the fact that decisions made were based on misinformation.”
When they asked if their daughter would have survived, Ms Wesson said the doctor told the couple: “Well, you could have miscarried anyway.”
Speaking previously to the BBC, she said: “That’s always stuck with me – it was almost malicious.”
The first test result – which the couple say was the basis on which they decided to terminate the pregnancy – had been a false positive. A later investigation said this is “a well-recognised hazard of early CVS results”.
‘The worst physical pain I’ve ever felt’
When Emmie Studencki started losing blood late during her second pregnancy in 2021 she went into hospital three times -but was sent home and told not to worry.
In a fourth bleed, she lost more than two pints of blood and was taken into hospital in Nottingham by ambulance but her ambulance notes were lost by maternity staff.
Emmie, now 37, and partner Ryan Parker, 39 had their requests for a caesarean section denied. She said: “I kept questioning why not but they just said: ‘You’ve given birth before, you can do it again’.”
No one informed the couple, from Barrowby, Lincolnshire, that she was suspected of having had a placental abruption – a dangerous complication where the placenta separates from the uterus wall too early, restricting oxygen supply to the baby.
A heart rate monitor showed their baby boy Quinn’s heart kept fluctuating – a sign of distress – and she suddenly developed “the worst physical pain I’ve ever felt” and started screaming. Although a doctor pressed the emergency button they say a nurse still refused her an emergency C-section, insisting it was not necessary and encouraging Emmie instead to go for a walk. When a doctor finally decided to break her waters, it triggered a massive haemorrhage.
Emmie rapidly lost seven pints of blood. She said: “The last thing I saw was blood everywhere and the next thing I knew I was coming around from surgery.”
When she woke up panicking about their son, the couple were first told everything was fine and then later that Quinn was “very poorly”. They say staff kept them apart for more than 10 hours, telling the couple it was “not a good time” to see him, before finally acknowledging that he would not survive.
Emmie said: “They robbed our time with him from us. We will never forgive them for that.” Quinn passed away in their arms when he was two days old. An inquest in 2022 found a “series of errors” in their care.
NUH was fined £1.6million last year after admitting criminal charges of causing avoidable harm to Quinn and exposing his mother to significant risk of avoidable harm, as well as failing to provide safe care in two other cases.
The couple, who both work in higher education, said NUH has repeatedly failed to be transparent over what happened and want to see a national public inquiry.
‘My daughter’s now expected to die in childhood’
Caitlin Stringer was born prematurely in 2021 at Nottingham City hospital and at 30 days developed necrotising enterocolitis (NEC), a severe, life-threatening gastrointestinal emergency.
Her parents told how the failure of staff to treat her quickly led her to collapse and suffer a severe brain injury.
The trust commissioned an external review and found an X-ray had been taken about 15 hours before Caitlin collapsed, which diagnosed NEC, and she should have been given antibiotics within an hour, which did not happen.
Mum Emily Stringer has told how Caitlin is now expected to die in childhood. She has cerebral palsy and has had multiple respiratory arrests at home.
Speaking previously, Emily told the Guardian: “She was in paediatric intensive care 13 times last year. We know that one day one of these will be fatal. It’s horrendous.”
Emily told the media briefing that the families “recognise there were good staff” who were working in a “bad environment”. She said: “They were also victims. Only accountability can incentivise that culture change in maternity services.”
