“Undoubted failings” by Nottingham City Hospital Led to Baby’s Death

Edward (Teddy) Errington-Rozkalns was born on November 23, 2020 at Nottingham City Hospital but sadly died the following day. Kim Errington (Teddy’s mother) was discharged from the hospital and returned home with Teddy she noticed that Teddy’s body was an abnormal colour as she placed him in his cot. Jason Rozkalns (Teddy’s father) performed CPR as they awaited the ambulance. The pediatric emergency team received a call from the ambulance and was informed that Teddy was in cardiac arrest. Upon arrival at the hospital, resuscitation was attempted but he could not be revived.

An HSIB investigation has revealed that it was not recognised that Teddy required hypoglycaemic screening.

The Inquest

An inquest was held into Teddy’s death In October 2021 however it was unable to determine the cause of death but concluded there were “undoubtedly failings” by Nottingham University Hospitals Trust (NUHT).

It was noted at the inquest, that Teddy’s birth was induced due to him being of small-for-gestational-age (SGA). Teddy weighed 2.52 kg (5lbs 5oz) and assistant coroner Laurinda Bower stated that he should have been placed on a “blood glucose pathway” in order to reduce the risk of hypoglycemia (low blood sugar level).

Miss Bower said:

 “It was worrying to hear that so many midwives, many of whom were of a number of years’ standing in the profession, had a misunderstanding of the criteria for commencing monitoring (for post-natal hypoglycemia) and that this misunderstanding had continued for so long – years in some cases.

“Midwife Cronin said she had been applying the same single, and incorrect, criteria regarding birthweight since 2015. That is five years prior to the error in Teddy’s case.

“The effect of the failure to monitor Teddy appropriately has not just had an impact on the care he received, but has led to an absence of evidence of blood sugar readings in life, which has had a profound impact on my ability to reach a conclusion as to the cause of Teddy’s death”.

Maternity staff unaware of guidelines on screening babies for blood glucose monitoring

The inquest heard that there was a misunderstanding among staff for the past five years as they were unaware that the guidelines were updated.

Ms Bower stated:

“This led to a failure to monitor baby’s blood glucose levels in the early neonatal period, and to his discharge from hospital without any such monitoring having informed the decision as to a safe discharge,” and there were “multiple missed opportunities to detect this error,”

“This has been accepted by the Trust. The care provided to Teddy failed to comply with local and national guidance, and further, the initial error was not detected despite multiple handovers of care involving multiple autonomous health professionals.”

Speaking to ITV News Central (February 2022), Kim Errington said,

“I was just so shocked at how wrong they could have got it and the fact that staff were supposed to be working from policies and procedures that are in place. But they weren’t. They just hadn’t. They hadn’t done their basic job.”

“He was a much wanted, and much-loved baby, and our hearts are broken because he is not with us today.”

Other Cases of Maternity Negligence at Nottingham University Hospitals Trust

Harriet Hawkins (2016)

Harriet Hawkins was delivered at Nottingham City Hospital in April 2016, nine hours after dying.

Harriet’s parents, Sarah and Jack Hawkins, were compensated £2.8 million in December 2021; this is believed to be the largest payout for a stillbirth clinical negligence case. The compensation awarded was said to reflect the considerable psychiatric injury caused by Harriet’s death and by NUHT’s failure to be open and transparent about the events which took place.

An external review of the case found 13 failures and concluded the death was “almost certainly preventable.”

The errors included:

  • Being eventually admitted to Nottingham City Hospital as the QMC had closed its doors to new admissions due to understaffing
  • Staff struggling to find a foetal heartbeat – and at one point finding Mrs Hawkins’, mistaking it for Harriet’s
  • Failing to diagnose active labour
  • Failing to review Mrs Hawkins before she was discharged after being given a “very significant” amount of opiates
  • Failing to perform a cervical exam before discharge
  • Failing to identify an obstetric emergency when Mrs Hawkins’ “waters were hanging out”
  • Leaving Mrs Hawkins in active labour for more than nine hours despite Harriet being dead

Harriet’s parents called for a change in the law which currently does not classify a stillborn child or foetus as a “deceased person” and therefore no inquests into such deaths.

The couple believe that if inquests had been held into other stillborn births at the trust, problems would have been identified and prompted changes that would have prevented Harriet’s death.

Wynter Andrews (2019)

Wynter Andrews was delivered by Caesarean section on 15 September 2019 at the Queen’s Medical Centre (QMC) but died shortly after.

An inquest at Nottingham Coroner’s Court noted a series of staff errors which included:

  • The failure to recognise Ms Andrews was in established and not latent labour,
  • The failure to act on high blood pressure readings
  • Four “inaccurate and insufficient handovers” to colleagues
  • A scan used to record the baby’s heartbeat was, however, incorrectly labelled as normal – despite showing a number of concerning decelerations

The cause of Wynter’s death was given as the entanglement of the umbilical cord being wrapped around her neck and acute chorioamnionitis – an inflammation of the placenta due to an infection.

Dr Gemma Wright, an obstetrician who was not involved in the care of Sarah Andrews, (Wynter’s mother), told the court if Sarah was granted a C-section one hour earlier it was likely Wynter would have survived.

Adele O’Sullivan (2021)

Adele O’Sullivan was born on April 17 2021at Nottingham City Hospital. She did not have a heartbeat and was declared dead 26 minutes later.

Despite Adele’s mother, Daniela experiencing bleeding and then back and abdominal pain on the evening of April 6 2021, it was not recognised that this was likely to be caused by a marginal abruption, followed by onset of preterm labour, leading to the separation of the placenta from the uterine wall in the second stage of labour.

An inquest into her death, led by Assistant Coroner Elizabeth Didcock, concluded on February 9 2022:

“I have no difficulty in finding that the delayed examination, the delayed recognition of labour, and the delayed diagnosis of the cause of the vaginal bleeding were missed opportunities to alter the plan of care for Daniela and Adele.

“But for these missed opportunities, would the outcome have been different in this case and would Adele have survived? On the evidence before me, I find that it is certainly possible, but for all of the reasons set out in this judgement, I cannot and do not find this on a balance of probabilities.”

Ms Didcock also commented that staff were “reactive rather than proactive”.

Bereaved Parents call for a public inquiry

Bereaved parents and other groups have asked for a public inquiry into maternity services at Nottingham’s hospitals trust. Sue Saddington, chairman of the county council’s health scrutiny committee, said she had put the request personally to the Health Secretary Sajid Javid.

In a statement released November 22 2021, Councillor Saddington said: “I am pleased to say that our concerns have been put in a letter to the Health Secretary and, at a recent event, he assured both myself and Councillor Barney that this would be referred to the Health Minister and dealt with accordingly.

“The maternity services issue at NUH is one we feel needs urgent attention and I am delighted that the Health Minister will be looking into it immediately and responding to our public inquiry request.”

A History of Mistakes and Negligence at Nottingham University Hospitals Maternity Services

NUH paid out £91m in compensation and costs from  2010 to 2020 in connection with brain damage suffered by 46 babies and 19 stillbirths.

In February 2022, Senior leaders at Nottingham University Hospitals Trust offered an apology to bereaved families and committed to improving inadequate maternity services within three years.

Director of Midwifery Sharon Wallis said:

“I left a really good, positive successful trust to come here. I trained at Nottingham and I feel like it’s full circle.

“It’s having that belief and recognition and learning from the past is so important that we do that and embed it. We’ve also got to look forward as well.”

She expressed the importance of absolutely “acknowledging what’s happened before and to all of our families that we have failed”.

Were mistakes made during childbirth?

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