Nottingham University Hospitals (NUH) NHS Trust has been fined £1.6 million for “avoidable failings” that led to the deaths of three babies in 2021.
The babies—Adele O’Sullivan, Kahlani Rawson, and Quinn Parker—died within 14 weeks of each other shortly after birth while under the trust’s care. On Monday, NUH admitted to six counts of failing to provide safe care and treatment to the babies and their mothers following a prosecution by the Care Quality Commission (CQC).
During sentencing at Nottingham Magistrates’ Court on Wednesday, District Judge Grace Leong extended her “deepest sympathy” to the grieving families, acknowledging that their trust in the hospital to deliver their babies safely had been “broken.”
Tragic Losses and Hospital Failures
Adele died just 26 minutes after birth on 7 April 2021, Kahlani passed away at four days old on 15 June, and Quinn died at two days old on 16 July. All three mothers had suffered a placental abruption—a serious condition where the placenta detaches from the womb prematurely.
The court heard that the hospital’s failures included inadequately trained staff, an inability to properly interpret cardiotocography (CTG) readings used to monitor foetal health, and delays in emergency interventions. Poor communication among medical staff also contributed to the deaths.
In a statement outside the court, lawyer Natalie Cosgrove, speaking on behalf of Quinn’s parents, said: “Although he never spoke, he has a voice, and it has been firmly heard. Quinn died from a long list of failings, and Emmie’s life was put at risk. Some failings were so basic that a passing stranger on the street would have provided better attention and quality of care.”
Sadie Simpson, representing Adele and Kahlani’s families, called the prosecution a “turning point,” saying it was yet another acknowledgment of “serious failures” in the trust’s maternity services.
Historic Fine and Ongoing Concerns
The £1.6 million fine, the largest ever imposed on an NHS trust for maternity failings, was initially set at £5.5 million but reduced due to the trust’s financial struggles and guilty plea. The CQC noted that this is the fifth maternity prosecution it has pursued, and the second time it has prosecuted NUH.
Judge Leong emphasized the lasting impact of these tragedies on the families, stating: “Three and a half years have gone by, yet for the families, their grief remains as raw as ever. The weight of what should have been done differently will linger indefinitely.”
Systemic Failures and the Trust’s Response
The court heard harrowing details of the circumstances leading to each baby’s death:
• Adele’s mother, Daniela O’Sullivan, was not given a vaginal examination despite experiencing pain and bleeding, leading to a delayed diagnosis of labour. An inquest later found “missed opportunities” in her care.
• Kahlani’s mother, Ellise Rawson, had complained of reduced foetal movement days before her emergency Caesarean. The trust admitted that monitoring was poor and key information was not shared with consultants. A coroner found that failings in care led to a 20-minute delay in the emergency procedure.
• Quinn’s mother, Emmie Studencki, visited the hospital four times before her son’s birth due to severe bleeding. On her final visit, an ambulance report recorded that she had lost 1,200ml of blood, but this information was not passed to hospital staff. An inquest found a series of errors contributed to Quinn’s death.The trust is currently under review in what has become the largest maternity investigation in NHS history, with approximately 2,500 cases under scrutiny. It was also fined £800,000 in 2023 for failures that led to the death of baby Wynter Andrews in 2019.
Commitment to Improvement
NUH chief executive Anthony May apologized for the failures, saying: “The mothers and families of these babies have had to endure things that no family should after the care provided by our hospitals failed them, and for that, I am truly sorry.”
He added that the trust is working to create a “safer and more effective maternity service,” and that hearing the families’ testimonies provided further motivation for improvement.
Helen Rawlings, the CQC’s director of operations in the Midlands, reinforced that regulatory oversight will continue, stating: “We will monitor the trust closely to ensure they are making and embedding improvements so that women and babies receive the safe care they deserve.”
In addition to the fine, the trust was ordered to pay £67,755 in prosecution costs and a £190 surcharge.
