A Hospital Consultant and his Senior Physiotherapist wife reveal how the death of their daughter has unearthed a dangerous catalogue of failings by Nottingham University Hospitals NHS Trust (NUH).
1. Introduction
2. Harriet’s Birth
3. Summary of failures of care during Sarah’s labour
4. Investigations
4.1 NUH – internal investigation (July 2016)
4.2 External Investigation - Serious Untoward Incident (SUI) Investigation: FIRST REVIEW (August 2016)
4.3 CCG Investigation (February 2017)
4.4 Midlands and East Local Supervising Authority (LSA) Investigation Report (June 2017)
4.5 External Investigation - Serious Untoward Incident (SUI) Investigation SECOND REVIEW [ongoing]
5. Impact on Jack and Sarah Hawkins
6. Inquests and Stillbirths
Appendix
A Timeline of events during Sarah Hawkins labour
B Midlands and East Local Supervising Authority (LSA) Investigation Report (June 2017) – available on request
1. Introduction
Baby Harriet Hawkins was born, dead, at Nottingham City Hospital on 17th April 2016. She was completely normal but she died intrapartum as a result of a mismanaged labour at Nottingham University Hospitals NHS Trust (NUH). Her father, Jack Hawkins, is a Hospital Consultant (Clinical Director in “NHS Improvement’s”). Her mother, Sarah Hawkins, is a Senior Physiotherapist. Both work at NUH.
Jack and Sarah are blowing-the-whistle on the gross errors made by NUH, the endemic failures and cover-ups by the Trust who seek to hide the true extent of the problems within their group of two hospitals (Queens Medical Centre (QMC), Nottingham City Hospital).
Baby Harriet was not the first to die. There have been several before her, and several since her death. Following pressure by Harriet’s parents on the NUH, it was admitted to them that between April 2014 and February 2017 there were 35 stillbirths. They also discovered that since March 2015 – and contrary to standard practice - the Trust had not conducted Serious Untoward Incident (SUI) Investigations into any of these Stillbirths. It was only after continued pressure from Jack and Sarah that the NUH decided to review one year’s worth of stillbirths, and upgraded 10 of them to SUIs.
Jack and Sarah believe Harriet’s death was completely avoidable. They are calling for a change in the law to broaden the jurisdiction of a Coroner to allow inquests to be held on babies after 37 weeks gestation. Currently they are unable to investigate a stillbirth (a baby born dead after 24 weeks of pregnancy). Had an Inquest been held into other stillborn babies at NUH, they would have identified problems within the hospital and prompted changes that would have prevented Harriet’s death.
This change to Coronial Law would bring England and Wales in line with Northern Ireland where, following a landmark legal ruling in 2013, it was held the “Coroner can carry out an inquest into the death of a stillborn child that had been capable of being born alive.”
Jack and Sarah are also calling for Trusts to share Stillbirth statistics with their local Coroner’s Office.
2. Harriet’s Birth
Harriet was Jack and Sarah’s first baby. There were no problems in the pregnancy and Sarah was considered low risk and suitable for midwife led delivery. It was planned for Sarah to give birth at Queen’s Medical Centre (QMC). Sarah began to experience contractions one day after her due date, the 11 th April 2016. She was in labour for 5 days before Harriet was eventually delivered. Between the 13th - 17th April, Sarah and Jack made 10 telephone calls to the Trust, and 2 visits to QMC where she was assessed, reassured and discharged home. These ‘touch points’ with NUH, are littered with gross errors and mismanagement which led to Harriet’s death.
Sarah was eventually admitted into Nottingham City Hospital because QMC had closed its doors to new admissions due to understaffing. She was found to be in the advanced stages of labour. Midwives and Doctors struggled to find a foetal heartbeat, on one occasion finding Sarah’s and mistaking this for Harriet’s. When an ultrasound was eventually carried out, it revealed that Harriet had died. Sarah was left struggling in an overly long labour. Nearly 10 hours later, Harriet was delivered weighing 6lbs 12oz.
A full timeline of events during Sarah’s labour is available at appendix A.
3. Summary of failures of care during Sarah’s labour
This is what a good maternity service should do:
1) Diagnose labour
2) Manage labour
3) Escalate if evidence of compromise to mother or baby
4) React appropriately to the escalation
5) Audit, investigate, learn.
Below is a long list of the various shortcomings in Sarah’s care:
a) Failure to diagnose labour: due to both the system at NUH and individuals who came into contact with Sarah.
b) Failure to diagnose active labour: see a)
c) Failure to review Sarah before discharging her after a very significant amount of opiates: guidelines state a doctor should review before and after administration but they did not.
d) Failure to perform cervical examination before discharge; this examination would almost certainly have resulted in Sarah staying in.
e) Failures to readmit Sarah after discharge despite 2 further phone calls.
f) QMC advised to come in but closed. City advised Sarah that she was not in “established labour” and told her “this is the opposite to what other women tell me when they are in labour”
g) Failure of team-lead midwife to access records to see previous admissions, despite Sarah informing her of large dose of opiates.
h) Failure by the team-lead midwife to identify an obstetric emergency when my waters were hanging out, which could have been the cord.
i) Failure by the midwifery team to identify an obstetric emergency and putting Sarah in the sanctuary birth suite.
j) Failure to recognise the real time of arrival at City hospital.
k) Failure of midwife to recognise it was maternal pulse, not Harriet’s, that she found.
l) Failure to identify an obstructed labour with 2000ml in Sarah’s bladder.
m) Leaving Sarah in active labour from over 9 hours despite Harriet being dead.
n) Failure of consultant to perform her ward round.
o) Failure of staff to be able to work bladder scanner which meant we had to revisit hospital.
p) Failure to submit a SUI when the national guidelines and every baby counts state all intrapartum deaths should be, it took 159 and an external review to get NUH to perform this.
q) Conducted a woefully inadequate RCA. No one spoke to Jack or Sarah…the missing phone calls were not identified until they showed them their phone bill. Even the place of Harriet’s death was incorrect.
r) Failure of NUH to communicate – direct email to medical director as no one was listening to us, his response was we will get back shortly, we never heard back.
s) Failure to involve the correct staff and to escalate Harriet’s death.
t) External reviewer appointed to post during review which significant alterations between the draft and final report.
u) Failure to adhere to the Duty of Candour.
v) Failure to refer midwifery practice to NMC despite patient safety being compromised.
w) Initial denial that we made two critical phone calls subsequently proven to have happened by Sarah’s phone bill. By denying us admission this midwife secured Harriet’s death. She has never been found and the documentation is missing.
x) Failure to trace receiver of phone calls so this midwife is still practicing and has not been involved in any review process.
y) Failure to keep promise to keep us updated on corrective action programmes.
z) “Variable” and contradictory accounts by same midwife to different enquiring bodies.
Investigations
In the early days after Harriet’s death the only contact Jack and Sarah had with NUH was with the Bereavement Midwife. At every meeting/phone call they explained that Harriet’s death was due to numerous errors and the couple expected to be contacted by NUH for the purposes of conducting an investigation. This didn’t happen.
Instead, they were told that a post mortem revealed Harriet’s death was caused by an ‘infection’ and to “try to move on”. Jack and Sarah were not prepared to be dismissed in this way. They knew something had gone horribly wrong and that the hospital were seeking to brush their concerns to one side.
4.1 NUH – internal investigation (July 2016)
Following repeated requests by Jack and Sarah, they eventually met with NUH in July 2016 to discuss what had happened. NUH said that having conducted an investigation (without their involvement) they’d concluded there were no errors by NUH and her death was down to an ‘infection’.
As an expert in infections, Jack was able to challenge this conclusion and the pathologist report. There was no pathogen isolated from culture; Sarah had no fever, no tachycardia, no abdominal tenderness and the amniotic fluid was clear. Had there been an infection serious enough to kill Harriet, Sarah would have been extremely unwell and probably required intensive care – instead Sarah was perfectly well.
Under pressure from Jack and Sarah, the NUH conceded that even with an infection, Harriet would at most have needed an overnight stay for antibiotics and observation. Furthermore, had they been ‘Private’ patients, Harriet would be alive.
Jack and Sarah demanded an external review of their case to be carried out and for second postmortem.
4.2 External Investigation - Serious Untoward Incident (SUI) Investigation: FIRST REVIEW (August 2016)
Once again, following pressure from Jack and Sara, NUH agreed to an external review in relation to Harriet’s death. They met with the external review team, headed by the lead midwife in Birmingham, Joy Payne in August 2016. They expressed their concerns about the Trust’s handling of Harriet’s death - likening it to the ‘Mid-Staffs cover up’. Following that meeting Harriet’s death was “upgraded” to a SUI, some 159 days after Harriet’s death.
An SUI should be declared within 72 hours of the incident and should be complete within 45 or 60 days. There is both local and national guidance as to what constitutes a serious incident. A death of a baby after 37 weeks is one such. Given the previous wide variation in how SUI’s were conducted across the NHS, there is now (and has been for years) an NHS policy.
During the investigation period Joy contacted the couple with updates, on one occasion expressing how the investigation was proving “difficult” and “this is massive” which Jack and Sarah took to mean either there was a lot to find out, or, more likely, that the investigation was uncovering major concerns. The investigation was due to be complete in the autumn but was put back at least twice.
They were sent a draft report in December 2016 to check for factual accuracy. It stated that “Harriet’s death was directly contributed to by five things”. This conclusion meant a great deal to Jack and Sarah, however it was to be short-lived. At the same time, Joy Payne, who was leading the external investigation, was approached by NUH to take on a post of Director of Midwifery – which she accepted.
When the final SUI report was circulated, the conclusions had been watered down to “Harriet’s death might have been avoided if…4 things…”
To Jack and Sarah, this significant change to the conclusions of the investigation report smacked of a cover-up, and a refusal to learn from the handling of Harriet’s birth. The Trust have refused to provide a written explanation as to why the investigation team changed their conclusions.
Dissatisfied with the handling of the SUI Investigation and report, Jack and Sarah informed the Clinical Commissioning Group (CCG) of the development.
4.3 CCG Investigation (February 2017)
The CCG cover large areas and buy the services from different providers, for example, maternity services at NUH. Their role is both financial prudence and safety. They need to know that the service they commission is safe.
In February 2017 the CCG pulled together a panel of representatives from NHS England, NHS Improvement, CQC and experts who considered the evidence surrounding Harriet’s death and the internal and external investigation that had followed.
From day one, the CCG have recognised Jack and Harriet’s concerns over NUH handling of the investigation into Harriet’s death, and recognise that the NUH maternity services had been allowed to get away from the usual external governance processes.
The CCG deem the first SUI to be “unfit”, not least as it fails to address the ‘route cause analysis’ (RCA) of Harriet’s death – something which should be at the heart of any SUI investigation. The CCG therefore organised for a new external review team to conduct a second SUI Investigation. This is currently ongoing and results are anticipated shortly.
4.4 Midlands and East Local Supervising Authority (LSA) Investigation Report (June 2017) [Investigation ID AK9117NOT631][Appendix B – available on request]
There has been an investigation by the Midlands and East LSA for Midwives into the handling of Sarah’s labour and Harriet’s stillbirth. Their report, published in June 2017, identifies a number of problems within the Trust and makes several recommendations [page 35 of the report]:
i. Improve formal electronic and paper record of communication between NUH sites.
ii. There are problems with the governance of the Trust in that there was no proper management investigation into Harriet’s birth. The Trust must review their governance systems, terms of reference and incident reporting to ensure incidents are escalated correctly and in a timely manner.
iii. Urgent review of the trust guidelines with the Band 7 (job band) involved within the incident.
iv. Review of the Telephone Triage System and Recording of Calls made so that the content of the calls can be accesses digitally and contemporaneously (rather than a paper system).
v. Band 7 training required to remind midwives of their professional accountability in completing records.
vi. Because of the limited engagement by Trust Supervisors of Midwives into the LSA’s investigation, they specifically recommend that the Head of Midwifery must remind midwives to particulate in investigations when requested.
The LSA’s investigation also made recommendations in relation to the midwives who came into contact with Sarah during her labour. Out of the 10 midwives Sarah encountered, eight must now undertake a Local Action Plan (training) and two of the midwives are to undertake a Local Supervising Authority Practice Programme (extensive programme of training amounting of between 150-450 hours).
4.5 External Investigation - Serious Untoward Incident (SUI) Investigation SECOND REVIEW
This second investigation is currently underway. In July 2017, Jack and Sarah met with the new investigation team. That meeting started with the lead investigator agreeing that “there was no evidence of an infection”. This has been a huge relief to Jack and Sarah.
5. Impact on Jack and Sarah
The death of Harriet, and the circumstances in which it arose has had huge impact on every aspect of the couple’s life: their work, careers, relationship with each, as well as family and friends. Not one aspect of their life has been unaffected.
Jack and Sarah have not been able to return to work and both suffer depression and PTSD. At several times since Harriet’s death they have both had such low points (often triggered by correspondence relating to their search for answers) they have both questioned the whether there is any point carrying on.
Jack is under the care of a Consultant Psychiatrist. Both Sarah and Jack are taking anti-depressants and counselling.
The impact of Harriet’s death includes:
• Flash backs
• Nightmares
• Insomnia
• Loss of work identity
• Being made to go to the ante natal clinic for bladder scan weeks after Harriet died. In their appointment letter they unhelpfully asked Sarah to make sure her bladder was full so they could “scan my pregnancy”
• The couple can’t look at babies, including their best friends baby, now 3 months old
• Being reviewed, post birth, by colleagues they normally work with
• They avoid people
• They lack the ability to go to social occasions
• They struggle to leave the house
• Passing the hospital when they go out (they live close)
• Seeing people in NHS uniforms
• Seeing new-born babies at the time Harriet died. Now it’s both new-born babies and toddlers the same age as Harriet, wondering what she would be doing now. And prams. Prams and smiling proud parents.
It is now some 18 months since Harriet was stillborn and her parents still feel they have not had an honest and empathetic apology from the Trust, Midwives or Doctors involved.
6. Inquests and Stillbirths
Under s1 of the Coroner and Justice Act 2009 a Coroner has a duty to investigate certain deaths if:
“A senior coroner who is made aware that the body of a deceased person is within that coroner’s area must as soon as practicable conduct an investigation into the person’s death if (a) the deceased died a violent or unnatural death, (b) the cause of death is unknown, or (c) the deceased died while in custody or otherwise in state detention.”
The current legislation means that neither a stillborn child nor a foetus is classed as a ‘deceased person’. If a baby dies after 24 weeks of pregnancy, before or during labour the death is classified as a stillbirth. A stillborn child or a miscarried foetus is not a ‘deceased person’ and there need not be an inquest. This is consistent with criminal law (under which destruction of a foetus is not a homicide) and medical law (where a foetus has no independent rights).
SANDS, the Stillbirth and Neonatal Death Charity describe the current system as “wholly inadequate” and campaign to “broaden the jurisdiction of the Coroner so that the Coroners are able to investigate a stillbirth should parents believe that the hospital’s internal review process will not adequately answer questions around their babies death.”
Had inquests been held into the deaths of over stillborn babies delivered at NUH, they may have highlighted the procedural, managerial and clinical inadequacies that resulted in Harriet’s death; thereby prompting changes within the NUH.
This change to Coronial Law would bring England and Wales in line with Northern Ireland (Sarah is from N.I.) where, following a landmark legal ruling in 2013, it was held the “Coroner can carry out an inquest into the death of a stillborn child that had been capable of being born alive.”
