Parents have told a court their lives feel empty and their families incomplete after babies died because of “serious and systemic” failures in maternity care at Nottingham University Hospitals.
Adele O’Sullivan, Kahlani Rawson, and Quinn Parker all died at Nottingham City Hospital within the space of four months in 2021.
Healthcare regulator the Care Quality Commission (CQC) brought charges against the hospital’s NHS trust for failing to provide safe care and treatment to the three babies and their mothers.
The case appeared at Nottingham Magistrates’ Court on Monday (10 February).
Nottingham University Hospitals NHS Trust (NUH) pleaded guilty to all six charges put to it relating to the deaths and the care of their mothers.
The court heard there had been “serious and systemic failures” in their care.
The charges were brought under the Health and Social Care Act for failure to provide safe maternity care and treatment, resulting in a significant risk of avoidable harm and, in one case, actual avoidable harm.
Following the trust’s guilty pleas, District Judge Grace Leong will decide on the sentence on Wednesday (12 February).
Possible outcomes include a significant fine for the trust.
Ryan Donoghue, representing the CQC, began proceedings with the first two charges, which related to Daniela O’Sullivan and her daughter, Adele.
Adele O’Sullivan was born and died at Nottingham City Hospital on 7 April 2021, having been born prematurely at 29 weeks.
Adele’s cause of death was severe intrapartum hypoxia, also known as birth asphyxia, which occurs when a foetus doesn’t receive enough oxygen during birth.
This had been caused by a placental abruption, which happens when the placenta separates from the inner wall of the uterus before birth.
Mr Donoghue told the court there had been no electronic handover, as well as delays and “missed opportunities”.
He said it should have been identified that Mrs O’Sullivan had been in labour sooner.
In speaking with several midwives, Mr Donoghue said some believed their workload had been “too high” and was “unsafe” due to staffing levels.
Mr Donoghue said the case had been reviewed by a CQC expert witness, who said this was “no excuse”, particularly because staffing issues were only present on the antenatal ward, where pregnant women are cared for, and transfers to the labour ward should have been done sooner.
NUH said staff levels on the labour ward were “adequate”, but the cases had been complex, Mr Donoghue added.
A statement from Mrs O’Sullivan, read by Mr Donoghue, said: “People who were supposed to help me did not help me, but harmed me, physically and mentally.
“Instead of bringing her home, I had to leave empty-handed. Our family will never be complete.”
Two further charges related to Ellise Rawson and her baby, Kahlani Rawson, who died in the neonatal unit at Nottingham City Hospital on 15 June 2021.
He died from a lack of oxygen, or hypoxic brain injury, and complications from placental abruption.
Mr Donoghue said the trust had accepted that the immediate escalation of his condition “should have taken place”, and that the quality of monitoring “was poor from the outset”.
The commission’s expert witnesses said it was “baffling” that a decision to deliver Kahlani was not made sooner.
Speaking in court, Amy Rawson, Kahlani’s grandmother and Ellise’s mother, said the past three years had been “arduous and stressful” and criticised the trust’s lack of transparency and empathy.
“We have no choice but to live with the loss of Kahlani,” she said. “We will most certainly never forgive any of you.”
The final two charges related to Emmie Studencki and her baby, Quinn Parker, who was born on 14 July 2021.
Baby Quinn died 36 hours later, on 16 July, in the neonatal intensive care unit after undergoing several blood transfusions. The cause of death was multiple organ failure.
Mr Donoghue told the court there had not always been an effective system for the transfer of information between East Midlands Ambulance Service (EMAS), which took Ms Studencki to hospital, and the hospital itself.
This led to incorrect information on how much blood Ms Studencki had lost. Ms Studencki had lost around 1.2 litres of blood before arriving at Nottingham City Hospital, but staff at the hospital believed this to be 200ml.
There had also been failures in the interpretation of a CTG, or cardiotocography, which is a technique used to monitor a baby’s heart rate and uterine contractions.
This was a common theme in the care of all three mothers and their babies, Mr Donoghue said.
A statement from Ms Studencki, read by Mr Donoghue, said the family is “still chasing the full truth and accountability”.
“It feels like when Quinn died, part of me died with him,” the statement read.
“A lot of the treatment set off alarm bells with us. We were left out, and we question the decisions that were made or not made.”
Father Ryan Parker also gave a statement, reading out a personal poem in the courtroom.
Bernard Thorogood, a specialist barrister representing the interests of NUH, issued a “profound expression of apology and regret”.
“It is impossible to really understand the nature and depth of the distress caused by the failures in the case,” he said.
Appealing to District Judge Leong, he said the trust had largely been free of previous convictions, excluding a conviction in January 2023, when NUH was fined £800,000 over serious failings in the care and treatment of mum Sarah Andrews and baby daughter, Wynter.
Wynter Andrews died at the Queen’s Medical Centre in 2019, in what was described by a coroner as “a clear and obvious case of neglect”.
He said this should be weighed in balance when deciding the sentence.
Mr Thorogood further said the trust must meet the cost of any fine itself, which will “restrict the capacity of the trust to provide services”.
In a statement, NUH Chief Executive Anthony May said:
“The mothers and families in these cases have had to endure things that no family should after the care provided by our hospitals failed them, and for that, I am truly sorry.
“These families have shown incredible strength during this time, and I can only imagine how painful it must have been for them to share their experiences again.
“The trust recognises the concerns raised by the CQC and has acted upon them to improve the services we provide to women and families in our care.
“The changes made mean that we are working in a different environment than in 2021, and we believe that we now have a safer and more effective maternity service.”
The case comes as senior midwife Donna Ockenden continues an independent investigation into the deaths and injuries of mothers and babies at Nottingham’s hospitals dating back to 2012.
More than 2,000 cases have been added to the process since it began in 2022, and the review is due to publish its findings in June 2026.
