Nottingham Coroners Court 7th October 2020 at 10am | Another baby that should have survived.
Wynter Sophia Andrews – who was the first baby for Gary and Sarah Andrews – was born at Nottingham City Hospital on 15th September 2019 but died very shortly after her birth.
Her parents are represented by Clinical Negligence solicitor, Natalie Cosgrove of Switalskis Solicitors. An Inquest into Wynter’s death took place at Nottingham Coroners Court 24th, 25th and 28th September. HM Assistant Coroner, Ms Laurinda Bower, will give her Conclusion at Nottingham Coroners Court on Wednesday 7th October at 10am.
Wynter’s mum, Sarah Andrews, was told that she was in latent labour when in fact it was established. She was left feeling ‘humiliated and worthless’ because her pain and condition was not believed. Over a period of several days she underwent several examinations and consultations with medical staff at the hospital. Despite clear signs that she was in established labour and a worrying CTG result, Sarah’s labour was allowed to continue without adequate progression. Eventually a decision was made to carry out a caesarean however the catalogue of errors meant that it was too late to deliver Wynter safely, and she died shortly after being delivered.
A Healthcare Safety Investigation Breach report (June 2020) into the circumstances of Wynter’s death has been conducted and identified a number of failings in her care.
Sarah, who works as a Care Manager for Nottingham County Council, is pursuing a claim against NUHT for clinical negligence. She suffers from PTSD as a result of what happened.
Neglect
The family’s legal team have asked the Coroner to make a finding of ‘neglect’ as there is stark evidence of gross failings in the care provided to Sarah Andrews whilst in labour with Wynter. Those failures were individual failures, allowed to occur within a culture that did not hold patient safety in sufficiently high regard, by an organisation that did not create proper or robust systems to protect patient safety.
No good explanations have been offered as to why the events of 14 and 15 September 2019 were allowed to take place. A number of witnesses accepted in terms that they had failed to follow basic, safety critical steps but had no real insight into why they had failed to do so.
Although some individuals sought to blame the systems that they worked within, or the pressures that were put on them, they all accepted owed an individual responsibility and duty to Sarah and Wynter Andrews. The tragedy of this case is that had almost any of those who were involved in the material care provided to Sarah Andrews met those basic standards then Wynter would have survived.
In medical cases it is not necessary for the Court to be satisfied that there was a complete failure to provide basic medical care or attention. Neglect can arise because of errors in clinical judgment that lead to the wrong diagnosis or treatment
Calls for an Inquiry into Patient Safety at NUHT
Sarah Andrews wants to ensure that nobody else should go through the experience that she and Gary have suffered. Whilst the Trust have produced an action plan, the family are concerned that the creation of more protocols and action plans will not affect the underlying cultural and staffing issues that have been identified in this case.
Many of the failures identified in this case occurred in circumstances where the individuals involved had guidelines or qualifications that should have pointed them in the right direction. There is no evidence that proper risk assessment tools are being used by co-ordinators. There is an absence of evidence of re-training of the individuals involved, or steps to ensure that staff in adequate numbers or seniority have been made available to the Unit, or that staff in general are provided with proper time for training or have been motivated to challenge other members of staff or escalate concerns about patient safety.
Of the steps proposed within the action plan, a significant number have not been actioned as of today’s date. The family are not satisfied that this Trust has the ability to reform its practices effectively. This comment is not made lightly and bears in mind not only this case but the lack of progress towards ensuring effective and safe maternity care in light of previous incidents and previous reports by the CQC highlighting safety issues in the provision of maternity care at the Trust. The family have asked that the coroner to consider writing to the Secretary of State for Health and Social Care notifying him of the issues arising in this case and asking him to arrange a review into maternity services at the Trust.
Duty of Candour
The family believe that the Trust has failed in its duty of candour under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Failure to follow the duty of candour is serious and amounts to a criminal offence. The failure of other Trusts to adhere to the duty has resulted in prosecution.
Following Wynter’s death, Sarah and Gary Andrews were not informed about the safety issues that are now acknowledged by the Trust and those responsible for Sarah’s care. Indeed, members of the Trust advised Gary and Sarah in terms that there were no issues in relation to her care and that Wynter’s death was unavoidable. The Trust’s failure to adhere to the duty of candour is highlighted within the HSIB report and prompted a letter of apology as late as August 2020. This apology does not excuse the Trust’s early lack of candour.
A lack of candour is not a peripheral issue. It goes to the heart of the Trust’s approach to patient safety and the way that it reacts following adverse incidents. The Trust’s apparent failure to meet that standard in this case is a regulatory issue that should be passed on to the relevant authority. The family has therefore asked the Coroner to refer this issue to the CQC for investigation.
