600 baby deaths to be reviewed in Nottingham hospitals maternity inquiry

A maternity review into Nottingham hospitals will include over 600 baby deaths, as per a freedom of information request.

This will account for 228 neonatal deaths and 409 stillbirths identified at Queen’s Medical Centre and City Hospital in the past decade.

Senior midwife Donna Ockenden, who examined cases involving 1,486 families affected by a maternity scandal at the Shrewsbury and Telford NHS Trust, will chair the investigation.The study is also expected to cover 20 maternal deaths and numerous instances of severe maternal harm and baby brain injuries.Nottingham University Hospitals disclosed details about letters sent to 1,378 women, inviting them to participate in the late 2022 review.

This does not include several others who reached out to the review independently, with the total cases expected to surpass 1,800.Of the 1,378 women, there were 1,541 'adverse events' recorded since 2012.

These events include stillbirth, neonatal death, brain damage, severe maternal harm, and maternal death.

However, not all these events were avoidable. Data indicates maternal deaths trace back to 2006.In total, the data reveals 657 combined baby and maternal deaths, 302 baby brain injuries, and 582 severe maternal harm incidents.

The year 2013 saw the peak with 165 incidents, while 2019 had the least with 113.

In 2021, 140 adverse events were reported.Jack Hawkins, whose baby Harriet died in 2016 after a catalogue of errors, said: "This is from a hospital that said it didn't have a problem and said Harriet's harm was isolated."We hope that as these numbers become clear maternity clinicians start to recognise the extent of harm done. We hope that they will start to recognise just what has been going on."Yearly breakdown of ‘adverse events’:2012: 1432013: 1652014: 1602015: 1592016: 1542017: 1472018: 1362019: 1132020: 1282021: 1402022 (up to September): 93.

Michelle Rhodes, chief nurse at NUH, said the trust was working closely with the review team. “We know that too many women and families have been let down by our maternity services, and we are fully committed to the Independent Review being led by Donna Ockenden which will make sure those individuals are heard.

“We have a comprehensive maternity improvement programme in place which is driving changes in our maternity services.

"These changes include staffing levels, training, compliance with guidelines, record keeping and the provision and use of equipment.

"We are striving for a culture where our teams feel supported to give the level of care we all wish to provide."

Initial open-book letters from NUH and Ms Ockenden were sent out to families across November 2022 and January 2023.

However, after a change in approach from opt-in to opt-out from September 25, a total of 1,092 letters were sent out to families by the review team.

This includes families who did not respond to the first letter, and families with new cases identified by the hospital trust since September 2022.

Ms Ockenden, who uncovered 200 avoidable baby deaths at Shrewsbury and Telford NHS Trust across two decades, said she was "so pleased" with the contact and engagement with local families. "As we progress with our work, my review team and I are absolutely committed to hearing and acting upon everything that families tell us," she said.

"We will continue to work positively and professionally with the trust, sharing our learning to ensure maternity care is made safer in Nottingham, now and in the future, for everyone that needs it.”

A recent inspection of NUH’s maternity services by the Care Quality Commission (CQC) found a number of improvements, moving the rating from ‘inadequate’ to ‘requires improvement’.

The impending police investigation is not expected to start until at least spring 2024.

Bereaved Nottingham families are among a group across the UK who are calling for a full statutory public inquiry into maternity safety in England.

The Group, named the Maternity Safety Alliance, say "fundamental reform" is needed after failures across Morecambe Bay, Shrewsbury and Telford, East Kent and Nottingham.

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