NHS trust fined over baby’s death just 23 minutes after birth

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An NHS trust has been forced to fork out £800,000 after admitting it failed to care for a mother and her daughter, who died just 23 minutes after being born. At a hearing on Wednesday at Nottingham Magistrates’ Court, the Nottingham University Hospitals NHS Trust pleaded guilty to two counts of failures in the care of Wynter Sophia Andrews and her mother Sarah Andrews, 33. 

It comes after Wynter Sophia died in the arms of her parents at the Queen’s Medical Centre in Nottingham just 23 minutes after she was born back in September 15, 2019. 

Wynter died of what is known as a foetal inflammatory response and foetal vascular malperfusion (umbilical cord obstruction), along with acute chorioamnionitis. This is an infection of the placenta, the amniotic fluid and umbilical cord compression during labour. 

She also died of hypoxic ischaemic encephalopathy, when a baby’s brain does not receive enough oxygen and/or blood flow near the time of birth.

This was determined after an inquest into her death in 2020. The inquest heard that Ms Andrews was admitted to hospital on September 14, six days after she originally began suffering contractions.

It was also discovered that Wynter’s loss of oxygen flow to her brain could have been prevented if staff delivered her earlier.

When she arrived at the hospital, Ms Andrews was reportedly “misdiagnosed” as being in the latent phase of labour, despite there being “clear clinical signs” that she was in established labour.  This meant she did not receive the level of care that was required. 

At the inquest, it was also heard that there were “missed opportunities” to move labour along and start one-to-one care, as well as missed chances to “provide additional monitoring” of Wynter’s wellbeing and to have “taken action if that monitoring had shown that baby Wynter was in distress”.

And was also revealed that a doctor seeing her the next morning failed to pick up on concerns raised by midwives about a potential infection or over a trace examination of the baby. 

District Judge Grace Leong said during the hearing at Nottingham magistrates’ court that the trust could have done far more to prevent the baby’s death. 

She said that the trust’s “failings and errors exposed Mrs Andrews and her baby to a significant risk of harm which was avoidable, and such errors ultimately resulted in the death of Wynter and post-traumatic stress for Mrs Andrews and Mr Andrews.

“My assessment is that the level of culpability is high, where offences on Wynter and Mrs Andrews are concerned. There were systems in place, but there were so many procedures and practices where guidance was not followed or adhered to or implemented.”

The coroner, Laurinda Bower, said the incident is a”clear and obvious case of neglect”. She said she received an anonymous letter from midwives on the unit 10 months before Wynter’s death urging the bosses to address the staffing levels amid concerns this could be “the cause of a potential disaster”.

Now, the trust is getting slapped with a hefty fine, which was reduced from £1.2million because of the guilty pleas. The trust has been given two years to pay it, as well as an additional £13,668 in costs and a victim surcharge of £181.

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The criminal prosecution was one of only two that the Care Quality Commission (CQC), the UK’s independent health regulator, has ever brought against an NHS maternity unit. The parents said the fine “demonstrated the seriousness” of the trust’s failings.

They added: “These criminal proceedings are designed to act as a punishment and a deterrent. No financial penalty will ever bring Wynter back. We hope [the fine] sends a clear message to the trust managers that they must hold patient safety in the highest regard.

“Sadly, we are not the only family harmed by the trust’s failings. We feel that this sentence isn’t just for Wynter, but it’s for all the babies who have gone before and after her.”

Trust chief executive Anthony May said he was “truly sorry for the pain and grief”.

He added: “We let them down at what should have been a joyous time in their lives”.

The trust said it was working to address the findings and had put in place a number of changes to its maternity services, such as boosted investment in training and equipment.

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