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Nottingham University NHS Trust has been told to make “significant and immediate improvements” to its maternity services.
The Care Quality Commission (CQC) told the NHS trust that its maternity and childcare services were still inadequate and mothers and babies may not be safe.
It follows the announcement of a new independent review, which will be led by Donna Ockenden, the same midwife who uncovered more than 200 avoidable baby deaths in Shropshire.
Ms Ockenden will examine more than 500 cases where babies died or babies or their mothers may have suffered harm while in the care of Nottingham University Hospitals’ NHS Trust.
She previously led the review into maternity failings at Shrewsbury and Telford NHS Trust. Her report, published in March, revealed a scandal that led to avoidable deaths over more than 20 years.
Bereaved families from Nottingham met Health Secretary Sajid Javid earlier this month to ask that Ms Ockenden take over the investigation into maternity services in the city.
On her appointment, Ms Ockenden said: “Having a baby is one of the most important times for a family and when women and their babies come into contact with NHS maternity services they should receive the very best and safest care.
“We already know that improvements to maternity care need to be made across the country and families in Nottingham have been through experiences that no family should ever have to go through.”
A review into services in Nottingham was already under way. It was commissioned last year by the local clinical commissioning group along with NHS England and NHS Improvement. Bereaved families had expressed growing concerns about the speed and independence of the inquiry.
Handing over the investigation to Ms Ockenden on Thursday, the initial inquiry team published its findings so far, detailing “indications of bullying behaviour” from some staff towards colleagues and patients. The report found a “defensive and fractious culture”.
It also said all maternity staff should have to pass an annual assessment to ensure they are monitoring a baby’s heart rate correctly and recommended establishing a dedicated 24/7 triage phone service.
Families have spoken of the “immense sense of relief” that Ms Ockenden will now investigate.
Jack and Sarah Hawkins both worked at Nottingham University Hospitals’ NHS Trust and had a lengthy battle following the death of their baby
Jack and Sarah Hawkins, whose daughter Harriet was stillborn in 2016, had to fight the trust to admit that its errors caused Harriet’s death.
At the time, Mr Hawkins was a consultant in acute medicine at the trust, and Mrs Hawkins worked there as a physiotherapist. They have both since left and are now whistleblowers after being blamed by hospital managers for their daughter’s death.
They had to take legal action to prove the trust was responsible.
They joined other bereaved families saying that the appointment of Ms Ockenden “signals the start of the next stage in the journey where families can now stop fighting and instead dedicate their strength, knowledge, and experiences to uncover the truth and improve maternity service for the people of Nottingham”.
Sarah Hawkins worked at the trust as a physiotherapist
Mr Javid said: “It’s absolutely vital that mothers and babies have access to the best possible care and I was deeply moved by the stories of families who have suffered from these tragic failings – my sympathies remain with all of them.
“I want to thank Donna Ockenden for stepping up to lead this crucial independent review. Donna will bring with her a wealth of experience, particularly following her work on the review of Shrewsbury and Telford maternity services, and I look forward to seeing her recommendations for urgent improvements.”
Sir David Sloman, chief operating officer at NHS England and Improvement, said: “We are sorry for the distress caused to the families in the delay in announcing a new chair for the review.
“We know we need to get this right for the families who have experienced such terrible loss and been through so much pain already.”
A spokesperson for NUH said: “We are passionate about improving our maternity care, and welcome the report from the independent review team.
“We will work through the recommendations in the report to make the changes. We thank the families and staff who have taken part in the review so far, and will continue to work with the new review team.”
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