Natalie Cosgrove represents the Andrews family, whose baby Wynter died as a consequence of neglect by Nottingham University Hospitals NHS Trust. The Coroner Miss Bower in her prevention of future deaths report commented on Lack of robust initial critical analysis of deaths and the unsafe culture within Midwifery Services. Further the Coroner referred the Trust to the Care Quality Commission (CQC) for review.
The CQC inspected maternity services at Nottingham City Hospital and Queen’s Medical Centre, run by Nottingham University Hospitals NHS Trust, on 14 and 15 October 2020.
CQC’s Chief Inspector of Hospitals, Professor Ted Baker, said:
During our visit to Nottingham University Hospitals NHS Trust’s maternity services, we were disappointed to find some serious concerns which were impacting on women’s care and safety.
We found fundamental practice like adequately risk assessing women and babies, was not always done. We also found staff did not always complete growth charts which enable staff to identify possible growth problems
Women’s notes were not comprehensive and not all staff could access them easily. We found that there was a combination of paper and electronic records in use across the unit. The main electronic records system was only accessed by midwives and was not able to be accessed in the community by GPs or community midwives.
When women transferred to a new team in the community, staff were unable to access their hospital records as there was no shared record keeping system. Managers told us, however, that plans were already in place to replace the current community records system with the same electronic system used in the hospital.
Following the inspection, we placed conditions on the trust’s registration and issued a warning notice to ensure mothers and babies experience the safe, effective and personalised care they are entitled to.
Natalie Cosgrove says of the report:
I am pleased to see that the CQC have taken a robust review of the Trust and the findings echo the Coroners concerns and my own. I am exceptionally concerned about the Trusts ability to enact change. During my investigations there are often promises of protocol changes, but protocols do not change the culture. I remain of the view that without a Public Inquiry and further rigorous review, then I will be representing clients year after year in very similar and sad circumstances. This cannot be right.
We already know of other incidents where failings in the Trust’s practices have brought about tragic circumstances for parents and would urge others to speak up if they feel that they may have been affected.
The CQC report is already attracting interest from the national media and Natalie provided comments in both of these articles:
- Lives of mothers and babies left in danger at Nottingham University hospitals trust – report (The Guardian)
- Maternity units rated ‘inadequate’ at NHS trust as parents demand inquiry(The Independent)