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Panorama - Season Episode 18 - Maternity Failures: The Fight for Justice
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00:05For a decade I've been investigating maternity services, hospital after
00:09hospital, failure after failure. She said it was just one-off, it was just one of
00:14those things, sometimes babies die, and when she left I said to Gary, I said
00:18something that's not right. Now in Nottingham, the biggest ever inquiry, the
00:23medical records of two and a half thousand families have been reviewed for
00:27instances of avoidable harm. There have been many families who have not been
00:33told the truth, they were told for years by the trust, that was just bad luck, it
00:38was only you. On Panorama, the mothers who weren't listened to. As soon as she made
00:46the first incision I screamed because I was in so much pain. And the staff who
00:52blew the whistle but were ignored. So how would you characterise the
00:58management's reaction to you later? It was inadequate. You would like to think that
01:05had they just learned that Quinn would be here and die from well and be outplayed.
01:23We were married in May, we moved house in June. In 2019, Gary and Sarah Andrews used their
01:30wedding day to share the news they were expecting a baby girl. We had smoke cannons that we held up,
01:36which were pink. It was a nice moment, nice gender reveal, big pink smoke outside. We had a pretty
01:42textbook pregnancy. It was only a couple of weeks before winter was actually delivered in the August
01:53that we had issues. Sarah had continuous contractions over six days, yet despite voicing
02:02her concerns, she was repeatedly told to stay at home. They were telling me I was okay and I believed
02:10them. She was finally admitted to a midwife-led unit at the Queen's Medical Centre, one of two hospitals
02:18run by the Nottingham University Hospitals Trust. On the car ride in, I was vomiting because I was just
02:25in pain. We felt like everybody was doing the best for us. Now, looking back on it, we realise how
02:33wrong it all was.
02:42At the hospital, the couple were left alone for long periods. How would you describe their attitude
02:48towards you? Very dismissive. I felt like I'd be better off dead than in the situation I was left in.
02:56Midwives failed to recognise that winter was stuck. They also missed clear signs of infection.
03:02Almost 24 hours later, Sarah was finally moved to the labour suite. Only now was a heart rate monitor
03:09attached, known as a CTG, a machine that can alert staff to a baby being in distress.
03:15They started doing the CTG monitoring. They kept commenting on her heart rate dipping.
03:23A midwife twice raised concerns about winter's heart rate to a doctor, but was ignored.
03:30Panorama has spoken to 10 midwives who worked at the Nottingham Trust. They've described a bullying
03:36culture where they were fearful of doctors and senior midwives. One has agreed to speak to us.
03:41We're protecting her identity as she's worried about speaking out.
03:46I think there was a lot of fear about using the buzzer, being told, you know, you don't need to
03:51buzz for
03:51that. You felt that the woman in front of you needed additional support. You pressed the buzzer and you
03:58were chastised for doing so. Yeah.
04:02Three hours after a midwife had first raised concerns, Sarah was finally sent for an emergency C-section.
04:09I felt moments away from meeting my daughter. It was only when we were in the operating theatre that
04:17it really hit me that something was gravely wrong. The mood in the theatre changed. There was suddenly
04:27a bit of an air of panic. That's when they discovered that there was a massive infection,
04:31because the smell of infection just filled the room.
04:36Winter was delivered alive, but seriously unwell, needing resuscitation.
04:44There was a clock at the top that said the time, and I was just watching it.
04:49And it was getting longer and longer and longer. And I remember 18 minutes thinking,
04:57they're not going to be able to help her. And it was at 23 minutes that they came over
05:07and told us that there's nothing else they could do.
05:20After Winter's death, Gary and Sarah were moved to a bereavement suite.
05:28We spent time just reading to her and talking about the future that would have been. And
05:35you can see me kind of smiling there, because in that moment, that's all I wanted in the world.
05:42The couple say they were told Winter's death was a tragic accident.
05:47The consultant that was involved in our care said it was just one off. It was just one of those
05:52things,
05:53sometimes babies die. And when she left, I said to Gary, I said something that's not right.
05:58An inquest into Winter's death revealed numerous failures to the hospital.
06:03Winter's death was preventable, say the coroner, a clear and obvious case of neglect.
06:09The hospital, however, had initially classed the death as expected when they'd reported it to the coroner.
06:15And it wasn't. She was a perfectly healthy baby. Perfectly healthy.
06:20The ticked expected in your case, it naturally begs the question of how many times
06:25the previously ticked expected in similar circumstances.
06:28There would have been so many families that just said, yeah, OK, without understanding that
06:34getting that death certificate issued means there's no further scrutiny from the coroner.
06:40Usually, serious incidents are reported to regulators who can then scrutinise them.
06:46The Nottingham Trust, however, devised its own classification system,
06:50which meant many serious incidents weren't reported to regulators.
07:06In 2022, Donna Ockenden, fresh from leading an inquiry into maternity care in Shrewsbury and Telford,
07:13was appointed chair of the Nottingham Review. She's been examining 2,500 cases from 2012 to 2025,
07:20the largest maternity inquiry in the history of the NHS.
07:34That's a way of hiding what's going on at the Trust.
07:38It's a way, definitely, of avoiding scrutiny. It is.
07:42And that's what Nottingham were doing? They were.
07:46At Winter's inquest, the way the hospital investigated deaths was heavily criticised,
07:51as the coroner was coming to her conclusion. An envelope landed on her desk.
07:57It contained a letter sent to the Trust's board ten months before Winter's death
08:03that predicted babies would die. It said inadequate staffing, poor senior leadership,
08:09and a lack of CTG machines meant the Trust was operating a service that is perilously close to
08:15being unsafe, and that mistakes will be inevitable, the consequence of which will be tragic for families.
08:22The letter was signed by more than 50 maternity staff.
08:26I visited the midwife who wrote it.
08:34The stuffing was really depleted, and people were demoralised and tired out.
08:40So how would you characterise the management's reaction to your letter?
08:46Oh, that's inadequate. All that they did was blame the HR department, that they had no idea that
08:53their staffing was so low. At the time I wrote that letter, people were being pulled away from
08:58their training. And that was very dangerous, because if you don't have the training, you're more likely not to deal
09:04with an emergency situation in the right way.
09:07While the NHS across England was short of some three and a half thousand midwives at the time,
09:13the Nottingham Trust didn't know how many it needed, as it was consistently miscalculating
09:19the number of midwives on each shift. It later discovered it was 73 midwives short around the time of
09:25winter's death. The Nottingham Review is the fourth inquiry into maternity services in England since 2013.
09:34Millions of pounds have been spent, hundreds of recommendations for improvement have been made.
09:40But the problems seemingly continue. Two more reviews in Leeds and Sussex have been ordered,
09:46and some families are pushing for a national inquiry.
09:50I've been an expert witness for 35 years. What I don't accept is Nottingham is any different.
09:56I think they're all the most terrible things, but they happen all over.
10:03A few weeks after Winter Andrew's death, her parents discovered they weren't alone.
10:11Hello, Jack. My name is Gary, and I'm the father of Winter Sophia.
10:15Gary had found another family similarly grieving.
10:18We feel that our daughter died as a result of similar failings
10:22to that of what I've read from your reports online.
10:26Hey, Gary, Sarah and Winter. What a beautiful name.
10:32I'm really pleased you've felt able to contact us. I am so sorry. My heart goes out to you.
10:38It's such an intensely painful feeling.
10:43Jack's daughter, Harriet, was stillborn in 2016. Both he and his wife, Sarah, were senior clinicians at
10:50the trust and were told their daughter's death was unavoidable, the result of an infection.
10:55I went to medical school for nearly six years. Sarah was completely well. For a baby to die because
11:04of infection in the womb, Mum would be sick. We knew that Harriet's death was avoidable.
11:12Despite ten phone calls and two visits to the hospital because of Sarah's painful contractions,
11:18the couple were repeatedly told to stay at home. Many families were given the same advice.
11:24Panorama has seen a resignation letter from a Nottingham midwife in 2018,
11:29raising concerns about attitudes towards mothers within the trust maternity services.
11:35I have overheard midwives diminish the autonomy and dignity of women. I don't like all this choice.
11:41Don't be too kind, she'll keep coming back. One coordinator writes F-O-H on a board as an
11:48abbreviation for F-O-H home. I read the letter to Jack and Sarah. That is horrific.
11:57I think that's quite upsetting for me to hear. Because that's what happened to us, isn't it? To you?
12:05Because I'm pretty sure that was probably written against my name. The last phone call
12:10I made to the ward manager, she might as well just said that to me. Who writes that in a
12:18caring
12:18profession, writes that on the board? Jack and Sarah had long believed they weren't the only ones
12:28who'd been harmed by the trust. You have nowhere to go. And then Sarah and Gary made contact. And
12:33you know, it's probably awful to say it, but it was a sense of relief. Right, we're going to get
12:37there.
12:38We'll find other people. We can do this. Sarah and I spent so many hours on social media,
12:46flicking through articles, trying to find someone who had been harmed or had a dead baby.
12:52Three years on, they'd connected with over a hundred harmed families. Together they pushed for
12:57Donna Ockrandon to lead the independent review of the Nottingham Trust's maternity services.
13:03There have been many families who have not been told the truth. They were told for years by the trust,
13:10that was just bad luck. It was only you. I think that it is a set of behaviours
13:18that are completely unacceptable. This was not, you know, run-of-the-mill maternity occurrences.
13:28It's been relentless over the ten years. There's always been something new that's come up.
13:33Just randomly on a subject access request, I had found out that they
13:41hadn't preserved Harriet in the mortuary.
13:47I mean, how low can you go? The problems of the trust extended to the mortuary.
13:54Poor care meant Harriet's body decomposed before she could be buried.
13:59Since the maternity review was announced, the entire leadership of the Nottingham Trust has changed.
14:05Anthony May, Cummina's chief executive, in 2022.
14:10Is there any reason to believe that the care of Harriet Hawkins's body was a one-off occurrence?
14:17It was Jack and Sarah who alerted me to the issue around the way we cared for
14:22Harriet's body. And I've had the chance, first of all, to say,
14:26sorry, there are things we need to do to improve our mortuary services. We are taking action to do that.
14:33What you are saying, my interpretation, is that it wasn't a one-off.
14:37I think there will be something in Donna's report about the way we've managed mortuary care.
14:44Panorama's been told that after the trust was alerted to its failures to preserve Harriet
14:49Hawkins's body, it commissioned an independent review of its mortuary services, which uncovered
14:55several problems. As time went on, the trust's argument that each case was a sad,
15:02isolated incident began to crumble. In 2021, Emmy and her partner, Ryan,
15:09were expecting their second baby, a boy called Quinn.
15:13It's quite striking, isn't it?
15:16Yeah, it's a nice way to remember, like, perfectly size Quinn was when he was born.
15:25The pregnancy was uncomplicated until Emmy experienced bleeding at 35 weeks.
15:31I was told that it wasn't anything to worry about, that it's very common,
15:37late stage in the pregnancy to bleed. I was, yeah, reassured that everything was okay.
15:48The bleeding continued for 10 days. The couple called and visited the hospital,
15:54but each time were reassured it wasn't significant and they could go home. But the bleeding was
15:59significant. I stood up and then there was a gush of blood coming down. I found the 999.
16:09Emmy was suffering a placental abruption, a serious condition that can be fatal for both mother and
16:15baby. The paramedic noted Emmy had lost as much as 1.2 litres of blood and had a rigid abdomen,
16:22both signs of an abruption. But the midwife who admitted her didn't properly record the details,
16:28meaning the hospital was unaware of how much blood Emmy had lost.
16:33The ambulance notes never made my medical records.
16:38Emmy was kept on the labour ward and expected to give birth naturally to Quinn.
16:43It was downplayed on their part and just to reassure me that I was in the best place I could
16:50be,
16:51that I was in active labour and I've given birth before so I can do it again.
16:57So I then asked, can I please have a cesarean? And I was told no.
17:05Medics suspected Emmy had a small percentile abruption, but didn't think it was severe enough
17:10to require urgent delivery. Quinn's heart rate was continuously monitored for 10 hours,
17:16but despite signs he was struggling, staff didn't immediately act. Eventually,
17:21medics tried to accelerate labour. It was the wrong decision. Quinn's heart rate plummeted and Emmy was
17:28sent for an emergency C-section. Quinn was born alive, but his parents say they were initially given
17:33differing accounts of how poorly he was. She just said he is a full-grown in terms of weight and
17:42looks like
17:43a healthy baby and we don't know what's happened and we can't explain as to why he is so poorly.
17:55Quinn died at two days old.
17:58An inquest would later reveal the placental
18:01abruption meant he was starved of oxygen while in the womb.
18:07This footprint was taken in the hospital.
18:12Well, it was taken out of the hospital.
18:15Yeah, when Quinn was still alive. Just a little keepsake.
18:24During the inquest, a mother contacted Emmy, whose baby had also died from a placental
18:29abruption just weeks before. Emmy then read about another similar death in a newspaper
18:35and messaged that mother. Quinn was in fact the third baby to die at the Nottingham Trust
18:42due to a placental abruption in just 14 weeks.
18:48Once an incident was investigated and there was found to have been some learning for the team,
18:56what's the follow-up training? Sometimes training would arise out of incidents. The outcomes,
19:05so what needed to happen as a result of an investigation, were really rarely enacted upon.
19:14So the actions quite often just got lost in amongst everything else.
19:21So we are talking about years upon years of external reviews, instructed by members of the board and still
19:28not acted upon. The senior leadership at Nottingham knew that their maternity services were not good
19:35enough or not good. Yes, yes. And they didn't do anything about it. That's absolutely correct.
19:41When you realised that you were the third family in a matter of weeks to have lost a child
19:48in similar circumstances. What did you think?
19:52Um, that it wasn't just one of those unfortunate and rare events that I've been told by the doctors.
20:01Had they just learnt, Quinn would be here and live and well and be up late.
20:16Last year, the trust was fined a record £1.6 million for the three placental abruption cases.
20:23It was the second time they'd been prosecuted for failing to keep mothers and babies safe.
20:29It was a landmark prosecution, but it would never bring Quinn back.
20:38When a failure to listen to women is ingrained, it doesn't matter how much agony she's in.
20:45In 2024, Yvonne and her husband, Avias, were on the labour ward in the Trust City Hospital,
20:51when they were told their baby was in distress.
20:54She was saying the baby's heart rate is dropping, but we need to assist you to give birth now.
21:00She needed a C-section and having had one previously, she knew what to expect.
21:06Doctors applied a local anaesthetic and checked if it was working, using a cold spray.
21:11If it was, she shouldn't be able to feel it.
21:14He asked me four times, can you feel the cold spray? And I repeated, yes, four times.
21:22As soon as she made the first incision, I screamed, because I was in so much pain.
21:33And the surgeon looked at me and she said, Yvonne, what you're feeling is pressure and not pain.
21:40Yvonne says she was in so much pain, medics were forced to hold their legs down.
21:46Her daughter, Naledi, was delivered healthfully.
21:51And at this point, I had literally just said to myself, if I die now, it's okay.
21:59At least I've heard my daughter crying.
22:01I remember hearing a woman saying, we're not going to sew her back up like this.
22:07We need to put her to sleep.
22:09And those were the last words I remember hearing.
22:13Yvonne and Avias say back on the postnatal ward, the anaesthetist came to speak to them.
22:20He came and knelt down next to my bed.
22:28Sorry, this is still hard for me to speak about.
22:31He just kept apologising. He was very sorry. He was very teary.
22:37He just kept saying, I'm really sorry about what happened.
22:39It shouldn't have happened, that I did say I was in pain and nobody listened to me.
22:46There's one question that I posed to this agent, that is this normal?
22:53Someone's screaming like that and no one talks about it after.
22:57And she said, it's normal.
23:01While the medics involved disputes some of what Yvonne says happened,
23:05the Nottingham Trust's chief executive told us her case is undoubtedly shocking and he'd like to meet her.
23:12The Nottingham Review is the first maternity inquiry centred on a large multi-ethnic population.
23:18The experiences of black and Asian families who have long had worse maternity outcomes
23:23due to racism and discriminatory care will be a key focus of the review.
23:29Did you see a racist practice?
23:30Yes, yes, sometimes. Women being shouted at for making too much noise.
23:37Yeah, Asian women, black women.
23:40There has been a 20% increase in maternal deaths over the past 15 years.
23:45The mortality rate for pregnant black women is almost three times higher than for white women.
23:51You were aware black women are more likely to die than white women.
23:56How did that impact you?
23:57I would be more vigilant.
24:00Everyone was aware, but whether that translated it into any kind of change in behaviour,
24:06because I'm sure that that three times, it's got to come from racism.
24:14It's how we look after people that's the problem.
24:19After Yvonne and Avias got home, the couple made a complaint about the failed anaesthetic.
24:24Is this part of the black minority discrimination or poor treatment in maternity care?
24:31These questions haunt me, and I cannot fathom why any woman, regardless of race or colour,
24:40should endure such such inhumane treatment.
24:45Do you believe that racism may have played a part in your experience?
24:53Obviously, there isn't anything I can say this was said racially.
24:58But sometimes it does play back in your mind, did this happen because I'm a black woman?
25:05I'm a black woman.
25:06Months before Yvonne's experience, Donna Ockenden had written to the trust, highlighting what she said
25:11were countless examples of racist and discriminatory behaviour, including staff
25:16mimicking patients' accents and non-white women being treated more dismissively.
25:21One of the first things I did was publicly say that we would tackle racism in this organisation
25:29because it's abhorrent and utterly unacceptable, and we did.
25:35The Department of Health and Social Care says its thoughts are with the families in Nottingham
25:40who have been failed so badly, and that it's recruiting 2,000 more midwives and investing
25:46£149 million to improve the safety of maternity and neonatal care facilities.
25:53Good morning, everyone. For anyone who doesn't know me, my name is Donna, Donna Ockenden,
25:58and I am privileged to be the chair of this...
26:02It's the final family meeting. The independent review is due to be published later this month.
26:08The efforts of these families have brought unprecedented scrutiny on the trust.
26:12There is also a separate ongoing police investigation into maternity care,
26:17with officers considering corporate manslaughter charges.
26:23Nottingham thought that there was a Nottingham way,
26:26that they were some kind of superior NHS trust compared to others in the region.
26:32My question is for the CQC. You know, you failed us. You knew about Harriet. You didn't believe us.
26:39Yes. The CQC agreed. I'm sorry.
26:48CQC, yes, I can't do so.
26:51We represent your local hospital and what we want to...
26:56So we're working really hard to make sure we are transparent and we've got processes that examine
27:02things properly, especially when they go wrong and we say sorry quickly and we're honest with families.
27:09Can you try again now? Roll it. Yay!
27:13Harriet and Winter needed each other. Shall Mummy roll it?
27:17Harriet needed Winter to show that they hadn't learnt.
27:21And Winter needed Harriet to show that they were repeating the same failures over and over again.
27:27And together our two little girls hopefully have made a difference and other babies won't have died because of them.
27:36Do you believe that whatever you find and publish in Nottingham will have a real impact on care nationally?
27:47I think that, you know, 2,500 families have shared the most harrowing details of what happened to them.
27:58It has to. It absolutely has to.
28:02But we're not alone. We're all in this together.
28:07We have got here because of us.
28:10The problems in maternity services have been well documented.
28:14What has been sorely lacking is a willingness to change practices, to listen to women and to learn from errors.
28:21Until that happens, too many families will continue to see the hope of new life give way to a lifetime
28:28of what-its.
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