News, Politics

‘Unacceptable’ families had to fight so hard to get baby deaths case to court, maternity chair says

By Joe Locker, Local Democracy Reporter

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The chair of Nottingham’s maternity review says it is “unacceptable” families had to fight so hard to get a case relating to the deaths of three babies heard at court.

On February 12, Nottingham University Hospitals NHS Trust (NUH), which runs the Queen’s Medical Centre and City Hospital, was fined £1.6m after admitting it failed to provide safe care and treatment to three babies.

Adele O’Sullivan, Kahlani Rawson and Quinn Parker all died within four months of each other at Nottingham City Hospital in 2021.

Healthcare regulator the Care Quality Commission (CQC) brought charges against the trust for failing to provide safe care and treatment to the three babies and their mothers.

The trust pleaded guilty to six charges put to it relating to the deaths, and the care of their mothers, at a hearing at Nottingham Magistrates’ Court on February 10 – almost four years since the death of the first baby, Adele, on April 7 2021.

District Judge Grace Leong later sentenced the trust to a total fine of £1.6m at another hearing on February 12.

She said families had their trust in the system “broken”.

NUH is currently at the centre of the largest maternity review in NHS history.

Senior midwife Donna Ockenden, the chair of the review, told the Local Democracy Reporting Service the battle the families fought to get the case heard was unacceptably long and hard.

“I’ve heard very clearly from the families the impact of that loss, the baby deaths, it has changed their lives forever,” she said at a briefing on Thursday (February 27).

“The very clear message the families have given me is – on top of the overwhelming grief at the loss of their babies – the battle they had to have with the CQC, first of all to get their voices heard, secondly to get the CQC to be interested, and thirdly to commence prosecution, was immense and it was long.

“From the families’ perspective, and I would agree, that is not acceptable.

“On top of overwhelming loss and grief, local families – and families across England – should not have to battle with the regulator to get them interested.

“The families believe that unless they had fought, they don’t believe the process would have ended up where it was.”

During the final hearing at Nottingham Magistrates’ Court, District Judge Leong also questioned why the case took so long to be presented by the CQC.

Ryan Donoghue, representing the commission, said the regulator had been “limited” in what work it could do itself before Nottinghamshire Police concluded its own investigation in the case.

The review comes after dozens of baby deaths and injuries at the trust.

A final report is now expected to be published in June 2026, having been delayed from September 2025.

This is because the number of cases has increased from 1,700 to an anticipated 2,500 families, once books are closed to new cases in May.

“On a really positive note I was so pleased to hear the trust had got significant success in midwifery recruitment and retention,” she said.

“My understanding is they haven’t had to use temporary agency staff in the trust since the end of January.

“The trust has listened very carefully to the many families and their own staff who came forward to the review with significant concerns around early pregnancy care.

“They have put in place a comprehensive plan of action to improve upon care that women get at a really, really difficult time in their pregnancy.”

However Ms Ockenden said there remain difficulties in communication, with some trust staff “adding to the distress that local families feel by the way they interact with them.”

“There are still concerns with both the quality and lack of timeliness of complaint responses, of the serious incident process, and then when families are asking for information from the trust there are often significant delays,” she added.

On March 3 a further 295 letters will be posted to families who were missed initially missed out, due to an error from the trust in understanding the terms of reference.

“They are families that we ideally would have written to some time ago, but can now assure we are now writing to them,” she said.

“Those cases are mostly baby deaths and baby brain damages, with a small numbers of families where mothers have died.”

Following the hearing, NUH chief executive, Anthony May, said: “The mothers and families of these babies have had to endure things that no family should after the care provided by our hospitals failed them, and for that I am truly sorry.

“Listening to them in court was moving and provided further incentive for us to continue to improve our services.

“The changes that we have made mean that we are working in a different environment than 2021 and we believe that we now have a safer and more effective maternity service.”

A CQC spokesperson said: “There are a number of enforcement actions CQC can and will take before prosecution to help drive improvement.

“But in cases where we consider evidential and public interest tests are met, we can bring a criminal prosecution. The evidential bar for prosecution is set to a high threshold.

“In the case of Nottingham University Hospitals NHS Trust, we hope that this particularly complex and difficult investigation and the resulting prosecution will drive real learning, deterrence and accountability as well as achieving justice for families.

“We would like to thank the families for their time and input into this prosecution and recognise that there are elements of the case for us as a regulator to reflect on and learn from.”