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A group of 100 individuals and their families who are members of an online support group for those affected by unsafe maternity services at Nottingham University Hospitals Trust have written to the Health and Social Care Secretary, Sajid Javid, asking him to appoint Donna Ockenden (who has recently delivered her report on maternity services at Shrewsbury & Telford Hospital NHS Trust) to conduct an independent review of maternity services at NUH.
In a letter to Mr Javid, they express their concerns about the current ‘thematic review’ being conducted, saying “Historically there have been reviews, nothing has changed. Coroners have publicly raised concerns, nothing has changed. If families are to be safeguarded, real and impactful intervention is required. The thematic review so far has been less than impactful, understaffed and moving with the viscosity of treacle. How can the public have faith in this process? The only answer is Donna Ockenden and a Public Inquiry.”
It is now 6 months into a 12-month review and the families believe that they must speak out now about their concerns over the thematic review if there is any chance of preventing more death and harm to babies, mothers, and families.
Flawed and inadequate independent review
For good reasons, the families have no confidence in the thematic review process or the review team presiding over it. The online support group has doubled in membership in the past few weeks to over 100 people (mainly mothers). They have shared harrowing accounts of maternity failures (many having taken place quite recently), as well as their poor experiences relating to engaging with the thematic review.
The thematic review is being led by the local Clinical Commissioning Group (CCG) and NHS England. The families have written to the Health Secretary highlighting the flaws and inadequacies of it, pointing out:
- The independence of the review is of significant concern which has been commissioned by two former employees of NUH.
- Not enough is being done to promote the Review or reach out to new families. There have been just two paid-for social media adverts (in March 2022) which saw the number of families contacting the review jump from 84 to 461 (as at 6/4/22) in just over a two-week period. More adverts need to be done to understand the true extent of those harmed.
- This Review currently has 3 clinical leads (1:154 families). The Ockenden Maternity Review employed 76 clinicians (1:20 families). The current team are unprepared and lack experienced leadership to handle a review of this magnitude.
The families say, “If we consider that in 6 months only 26 families have been spoken to, how can the public have faith that the other 361 families will not only be listened to, but purposeful conclusions made? It will either be rushed or drag on, whereas Donna Ockenden has the team, and a Public Inquiry has definitive timelines. The affected families and general public deserve that certainty.”
NUH have repeatedly proven themselves incapable of effecting change
Despite repeated and significant public scrutiny over many years, from varying sources, including Coroners Prevention of Future Death reports; HSIB reports; CCG investigations; NHS Resolution report; failures to respond following clinical incidents; complaints by families and significant media interests into the maternity scandal at NUH - babies, mothers and their families continue to be harmed. As such, NUH have shown themselves incapable of change which is why a proper independent review must be conducted by Donna Ockenden, leading to a full Public Inquiry.
There have been 34 maternity investigations (that are known of) following adverse incidents at NUH since 2018.
They have involved:
- Three maternal deaths
- 22 babies who faced potential severe brain injury
- Four neonatal deaths
- Five stillbirths
A Healthcare Safety Investigation Branch (HSIB) identified numerous deficiencies in care and made 74 recommendations to NUH across all the cases they investigated. The trust was identified as an "outlier" in relation to the incidence of neonatal deaths, stillbirths and the number of babies requiring cooling following birth by HSIB, according to the CQC inspection in 2020. The regulator also found "little evidence" the HSIB recommendations were being acted upon.
In 2020 both maternity services run by NUH were rated as inadequate by the Care Quality Commission (CQC).A reinspection in March 2022 saw NUH issued with a warning notice which also highlighted increases in stillbirths and some midwives acting outside of their competence in respect of reviewing their scans.
An investigation by Channel 4 News and the Independent in July 2021 reported 46 babies had suffered brain damage and 19 were stillborn in Nottingham in recent years.
Sarah and Dr Jack Hawkins
Senior NHS Physiotherapist Sarah and Dr Jack Hawkins whistle blew the problems at NUH following the death of their daughter, Harriet, who died intrapartum on 17th April 2016 as a result of a mismanaged labour. At the time the couple both worked for NUHT - Jack was a Hospital Consultant (Clinical Director in the Emergency Care Improvement Support Team of NHS Improvement) and Sarah, a Senior Physiotherapist.
Because Harriet was stillborn, there was no inquest into her death, and the couple were told she had “died of an infection”. Their medical knowledge meant they knew this to be untrue, therefore with the support of their solicitors (Switalskis Solicitors) they embarked on their own investigations to discover the truth behind their daughter’s death which exposed the inadequacies in NUH’s maternity services.
They continue to coordinate and uncover experiences of others who have experience maternity trauma at NUH. In short, they are doing a job the independent review should be doing. New families don’t know where to turn for support and are, instead, turning to an online support group for guidance. Each new story shared forces the couple to relive their own trauma, but they do so in memory of Harriet and all the other babies who have died.
