An NHS trust which failed to provide safe treatment to three babies who died within weeks of each other has been fined a record £1.6 million. Adele O'Sullivan, Kahlani Rawson and Quinn Parker died in 2021 while under the care of the Nottingham University Hospitals NHS Trust. The trust, which is at the centre of the largest maternity inquiry in NHS history, admitted failing the babies and their mothers.
It was previously fined £800,000 in 2023 following the death of another baby, Wynter Andrews, who died in 2019. But the latest fine, handed down by a judge at Nottingham magistrates’ court, is double the amount. NUH becomes the first trust to be prosecuted by healthcare watchdog the Care Quality Commission more than once. It pleaded guilty to six counts of failing to provide safe care and treatment to Adele, Kahlani and Quinn and their mothers. The three babies were born at Nottingham City Hospital, one of two main hospitals run by the trust. In all three cases the mothers suffered a placental abruption - in which the placenta starts to come away from the wall of the womb.
“Serious and systemic” failures exposed Daniela O'Sullivan, Ellise Rawson and Emmie Studencki, and their babies to significant risk of harm. District Judge Grace Leong said the “catalogue of failures” in the trust’s maternity unit were “avoidable and should never have happened”. Family members of the three babies cried as she expressed her “deepest sympathy” to each of them. The judge said the trust they put in NUH to deliver their babies safely had been “broken”. She went on: “The death of a child is a tragedy beyond words, and where that loss is avoidable the pain is even more profound. For the families no doubt their grief remains as raw as ever and a constant presence in their lives that is woven into every moment.
“The grief of a baby is not just about the past, it is about the future that is stolen. It is a lifetime of missing first words, first steps, first days of school, missing memories that should have been made. It is very difficult, if not impossible, to move on from the failures of the trust and its maternity unit. The weight of what should have been done different will linger indefinitely.”. The CQC says the trust did not ensure safe care and treatment due to a lack of adequate systems and processes being in place. District Judge Leong said: “I accept there were systems in place. But there were so many procedures where guidance was not followed or adhered to. The failures in combination amounted to systematic failures in the provision of care and treatment. A significant financial penalty has to be fixed to mark the gravity of these offences and hold the trust to account for their failings.”.
The trust was also ordered to pay prosecution costs of more than £67,000 as well as a surcharge of £190. In a victim impact statement Mrs O’Sullivan said the death of her “beautiful daughter” left her “mentally and physically” scarred. She added: “Instead of bringing her home I had to leave the labour suite empty handed in a lot of physical and mental pain.". Kahlani’s grandmother Amy Rawson said her grandson's death left the family "devastated, broken and numb".
