Baby’s death at Nottingham City Hospital ‘almost certainly preventable’

A scan showing a healthy Harriet Hawkins earlier in Sarah's pregnancy.

An external report into the stillbirth of a baby at Nottingham City Hospital has concluded her death was “almost certainly preventable”.

Harriet Hawkins was delivered at the hospital in April 2016, hours after she had died.

Her parents, Sarah and Jack, have accused the hospital of a lack of transparency over the case.

The hospital’s ruling trust has already apologised, and said previously failings in Sarah’s care were so serious Harriet may have survived if her treatment had been better.

The couple’s solicitors are now referring the death to the Crown Prosecution Service, meaning they are seeking a criminal prosecution.

The details are also being passed to the Health and Safety Executive and the professional bodies of staff who oversaw the labour and delivery.

Harriet was born dead after nearly 41 weeks of pregnancy and what later reports have shown was a catalogue of errors in Sarah’s care. The couple say they were at first told by staff Harriet’s death was caused by an infection, but later pushed for more answers and external reviews.

On Wednesday (January 10) the family released part of a Root Cause Analysis Investigation Report, written following an official external investigation into the care Sarah received around the time of Harriet’s death.

It identifies 13 ‘care and delivery problems’ and contributory factors in the case.

They include the failure of staff to take Sarah’s full clinical history, the administration of opiates (strong painkillers) during the early stage of labour, and misinterpretation of the findings of a post mortem examination into Harriet’s death.

Both Sarah and Jack work for Nottingham University Hospitals NHS Trust, which runs both the Queen’s Medical Centre and City Hospital, Sarah as a senior physiotherapist and Jack as a consultant and clinical director for NHS Improvement.

Jack said: “There is no doubt that we have blown the whistle on bad practice and management at the trust where we are both employed. However come January 2018, I will have no job with them and Sarah will be on half pay and likely no pay in 4 months’ time’.

“We are both unable to work because of the psychological and psychiatric impact Harriet’s death has had on us. The conduct of the trust towards us is compounding that impact.”

Sarah and Jack Hawkins.

Tracy Taylor, Chief Executive for the trust, again offered condolences to Sarah Jack, saying: “I profoundly apologise that we let them and Harriet down so badly. NUH has acknowledged that it is likely Harriet would have survived had it not been for several shortcomings in care.

“We welcomed the independent review commissioned by our local commissioner, following the previous external review, which provided a further opportunity for our teams to reflect and learn from this incredibly sad case. We accept the recommendations that have arisen from the external review, and have worked to ensure appropriate further actions have been taken where needed.

“We are sorry that we did not communicate as effectively as we should have early in this process, but have since sought to communicate openly and frequently with Jack and Sarah to keep them updated of our investigations. An external investigation into Harriet’s death commenced as soon as practically possible after the family raised concerns.”

She said the trust staff sickness policy has been followed “fully and properly” and ‘appropriate’ salary payments have been made to Jack and Sarah during this period.

Changes had been made to hospital care systems and processes since the case and review of maternity services has also been conducted, she added.

Video: Sarah and Jack Hawkins speaking to Notts TV in October.

“NUH has completed a full review of patient safety and outcomes in its maternity service,” she said.

“While areas of improvement have been identified, there is no evidence to suggest that outcomes in our maternity services are different to those in other similar maternity units in England and Wales. We have learnt from all of these incidents and are committed to doing everything we can to provide the safest and best quality care for our mothers and babies.”

The family’s lawyer, Janet Baker, from Switalskis Solicitors, said: “This report is so damning that we are considering the unusual step of referring a number of the staff involved in Sarah’s care to their professional disciplinary and regulatory bodies and asking the Health and Safety Executive and Crown Prosecution Service to respectively investigate the systemic and institutional failings and the lack of candour identified in the report.”