A former Nottingham midwife’s daughter was left with a serious brain injury after “days” of missed and delayed care by the trust she used to work at.
Four-and-a-half-year-old Caitlin was born under Nottingham University Hospitals Trust (NUH) in 2021 to Carlton parents Emily Stringer, 36, and Darryl Gwinnett, 38.
Born prematurely, she was transferred to the neonatal unit to continue growing in an incubator, but her parents say she was a “completely healthy” baby.
Caitlin’s devastating case started at just a few weeks old, when her parents noticed her abdomen had become very swollen. She became lethargic and was struggling with her feeds and the oxygen she was on.
Necrotising enterocolitis was her condition, the symptoms of which were initially ignored by staff on the unit, despite Caitlin’s parents raising concerns for “days”.
The life-threatening illness is the most common surgical emergency in newborn babies, particularly those born prematurely, and is where tissues in the intestine become inflamed and start to die. If not treated swiftly, it can lead to a dangerous infection.
Now, the four-year-old is living with a life-changing brain injury from the complications of missed and delayed intervention and is not expected to survive childhood.
Emily Stringer said: “We were taking photos of her increasingly swollen abdomen, and they were all addressed in isolation – no one took a step back and thought, ‘Hang on, these parents are right. This is a deteriorating baby.’”
“Ultimately, we were right. Caitlin’s bowel ruptured, and then she collapsed,” Ms Stringer continued, adding her daughter was not given antibiotics until 17 hours after an X-ray had confirmed the problem – the national standard is within one hour.
Ms Stringer worked as a midwife at NUH until resigning in 2018 after not having the “strength” to deal with the toxic “sink or swim” culture within the trust’s maternity service. It was some of her former colleagues who were responsible for Caitlin’s care after she was born.
She said: “I was told to be a mum, not a midwife; essentially, shut down as a professional.
“Having worked at the trust, I knew the issues the maternity service was facing, and I thought my knowledge would be enough to keep me and Caitlin safe.
“To some extent, I feel quite protective of the midwives there because there are some truly great ones doing their absolute best in dire circumstances.”
Her partner, Darryl Gwinnett, said: “[Emily] had the knowledge to ask the right questions, and that still wasn’t enough, but on the days she wasn’t there and it was me, someone with no healthcare background, I was just constantly lied to and dismissed.
“If someone with Emily’s background can’t even steer the staff into the right outcome, what chance has anyone else got?”
Today, Caitlin cannot walk, cannot hold her head up, is non-verbal, and is fed via a tube into her stomach because she cannot safely swallow.
Mr Gwinnett said, “Despite all of that, she is the happiest little girl you can imagine. She’s a little daredevil,” with Ms Stringer adding: “She thinks she’s got the best life ever.”
Caitlin and her parents are part of Donna Ockenden’s independent maternity review, the largest review in NHS history, which has unveiled the harrowing maternity care failings leading to the harm and death of 2,430 mothers and babies.
The nearly four-year review was published on Wednesday (24 June), examining 2,505 cases of death and serious harm, including 838 current or former staff giving evidence.
Of the cases, 612 related to severe maternal harm, 505 related to stillbirths, 329 related to neonatal deaths – within the first 28 days of life – 297 related to brain injuries at birth, 24 related to maternal deaths, and 535 related to additional maternity experiences.
Distressing details from the report include that 156 babies could have survived had better care been provided by NUH over a period of 13 years, relating to 94 stillbirths and 62 neonatal deaths.
It also found 105 potentially avoidable severe brain injuries inflicted on babies and disturbing events, including one deceased baby being placed by a portering staff member into a mortuary space already occupied by an unrelated deceased adult, and another early gestational baby being “inadvertently” disposed of as clinical waste.
In her statement, expert midwife Ms Ockenden said a “toxic culture” was able to take hold across NUH maternity services, where a “small number of powerful leaders infected the unit”.
She said bullying was normalised, speaking up was dangerous, and junior staff were afraid to escalate concerns.
Mr Gwinnett continued: “I think the most heartbreaking thing is just knowing [Caitlin] should have had a better life, and it’s kind of bittersweet that she doesn’t understand what her life should have been like.
“We’ve left her today [Wednesday, 24 June] in intensive care because she’s back in there… Every time she’s ill, we have to trust the same organisation that harmed her.”
NUH’s board meets on Thursday (25 June) with families in attendance, where Nick Carver, NUH chair, said he and the chief executive, Anthony May, have agreed with impacted families to work with them on a “full and meaningful apology” once the whole report had been considered, but said the board was “sincerely sorry” for the families’ harm.
He said NUH was “absolutely committed” to ongoing improvements, openness and transparency, and long-term engagement with families.
Mr May, speaking on Wednesday, said improvements across NUH’s maternity service are already apparent.
He said: “Against the 10 safety recommendations by which we’re all judged in maternity, when I joined [the trust, in 2022], we met five of them – we now meet 10 – so that’s more than words, that’s action.
“When I joined, there were 126 vacancies for midwives. Now we’ve got about 15. We’re still trying to recruit more doctors; that’s more difficult.”
At Thursday’s board meeting, the trust announced that Sherwood Forest MP Michelle Welsh (Lab) – who suffered her own traumatic birth experience under NUH with her son in 2020 – would be chairing its learning and improvement board to oversee changes to its maternity service.
Ockenden’s report includes eight “immediate” and “essential” actions NUH must work on.
These are: improvements in listening to women and families; workforce planning and safe staffing; training and multi-professional learning; risk assessment throughout pregnancy; incident investigation and family involvement; governance and board accountability; culture, teamwork and psychological safety; mothers who have died; and post-death care.
Impacted families are calling on the Prime Minister, Keir Starmer, to set up a public inquiry into national maternity services “without delay”.
By Lauren Monaghan, Local democracy Reporter