NHS Trust Fined £1.6 Million for Failures in Maternity Care Leading to Baby Deaths
An NHS trust has been fined £1.6 million after admitting to severe failings in its maternity care that contributed to the deaths of three newborn babies in 2021. Nottingham University Hospitals (NUH) NHS Trust pleaded guilty to six charges of failing to provide safe care and treatment to the three infants and their mothers at Nottingham Magistrates’ Court. The deaths of Adele O’Sullivan, Kahlani Rawson, and Quinn Parker, all of whom passed away within days of their births, were described by District Judge Grace Leong as “avoidable tragedies” that should never have occurred. The judge emphasized that the trust’s failures were systematic and deeply impactful, leaving the families with lifelong grief and unanswered questions.
The court heard harrowing details about the circumstances surrounding each death, which highlighted a catalogue of failures within the trust’s maternity unit. In the case of Quinn Parker, his mother, Emmie Studencki, experienced severe bleeding in the days leading up to his birth but was not adequately monitored or treated. Despite losing an estimated 1.2 liters of blood, hospital staff recorded only 200ml, delaying critical interventions. Quinn was born via emergency Caesarean section but suffered multiple organ failure and brain damage due to a lack of oxygen, leading to his death. An inquest later concluded that earlier intervention might have saved his life. Studencki described the trust’s treatment of her and her family as “contemptuous and inhumane,” reflecting the profound betrayal felt by all three families involved.
Adele O’Sullivan was just 26 minutes old when she died after being born at 29 weeks via emergency Caesarean section. Her mother, Daniela, had experienced bleeding and abdominal pain but was left unexamined for eight hours despite her high-risk pregnancy. By the time Adele was born, she was in poor condition, and care was withdrawn. Daniela described how the pain and trauma of the experience left her with lasting physical and mental scars, saying, “People who were supposed to help me did not help but harmed me forever.” Similarly, Kahlani Rawson died four days after his birth due to delays in providing an emergency Caesarean section for his mother, Ellise, who had reported reduced fetal movements and abdominal pain. Kahlani suffered a brain injury and passed away, with his grandmother calling his death a “preventable tragedy” that left the family “devastated and broken.”
District Judge Leong identified several systemic issues within the trust’s maternity unit, including a lack of proper escalation of care, inadequate communication systems, and failures in sharing “clear and complete” information between staff. She acknowledged that while systems were in place, they were not followed or adhered to, leading to a cascade of avoidable errors. The judge expressed her “deepest sympathy” to the families, recognizing that their grief remains as raw as ever and continues to shape their lives. She also acknowledged the financial challenges faced by the trust, which operates with a £100 million deficit, but stressed that the fine was necessary to reflect the gravity of the failures.
The fine of £1.6 million was broken down into specific amounts related to each case, with £700,000 for Quinn’s death, £300,000 each for Adele and Kahlani, and £100,000 for the care provided to each of their mothers. The trust’s lawyers apologized to the families and outlined steps taken to improve care, including hiring more midwives and providing additional staff training. However, for the families, these measures come too late. Their losses are irreplaceable, and the trust’s admissions have only underscored the pain of knowing that their children’s deaths might have been prevented with better care.
This case is not the first time NUH NHS Trust has faced accountability for maternity care failings. In 2019, it was fined £800,000 following the death of another baby just 23 minutes after birth. The trust is now at the center of the largest maternity inquiry in NHS history, led by midwife Donna Ockenden, which is examining more than 2,000 cases of potential failings in maternity care. The inquiry’s findings, delayed until June 2026, are expected to reveal further systemic issues and recommendations for improvement.
In a statement after the hearing, NUH’s chief executive, Anthony May, apologized to the families and acknowledged the trust’s failings. He emphasized that improvements had been made, including changes to maternity services that have already led to better ratings in recent inspections. However, for the families of Adele, Kahlani, and Quinn, no amount of improvement can undo the harm caused by the trust’s systematic failures. Their stories serve as a stark reminder of the importance of accountability in healthcare and the need for ongoing vigilance to ensure that all mothers and babies receive the safe, compassionate care they deserve.
