Bosses at the NHS Trust which runs Nottingham's main hospitals have apologised to two of their own employees whose daughter was still born, and admitted that shortcomings in her care might have caused her death.
Sarah and Jack Hawkins - who is a director at an NHS watchdog - have accused the Trust of a lack of humanity, and believe their daughter Harriet would be alive had dozens of similar deaths been properly investigated.
Harriet was stillborn at Nottingham City Hospital - killed, say her parents, by midwives' incompetence.
Sarah was in labour for five days; the couple made ten phone calls and two visits to the Queen's medical centre in that time.
They say they were patronised, dismissed and made to feel like frauds by midwives, and claim 26 separate failings, including:
- A failure to diagnose that Sarah was in labour at all
- A failure to identify an obstetric emergency
- A failure to find Harriet's heartbeat when Sarah was eventually admitted - at one point staff mistook Sarah's pulse for her daughter's
There was also a failure to report Harriet's death as a Serious Untoward Incident, which would have brought with it a higher standard of investigation - and in this regard, her parents later discovered, her case is not isolated.
They asked how many similar deaths there were to Harriet's, and discovered there were 35 in just over two and a half years.
Since then the trust have looked at thirteen of those death and subsequently upgraded them to Serious Untoward Incidents".
The couple see the deaths as 35 missed opportunities to have prevented their daughter's.
Acknowledging shortcomings in Sarah's care, Nottingham University Hospitals NHS Trust apologised unreservedly.