Nottingham is a place close to my heart, and I was very distressed to read this week the findings of an investigation into the sad death of baby Harriet Hawkins at Nottingham City Hospital in April 2016. Harriet was stillborn after her mother Sarah endured a five-day labour.
The independent investigation into Harriet's death last December found several contributing factors, including:
- "lack of midwifery leadership"
- "inadequate processes to support communication of clinical information"
- "poor safety culture"
- "lack of governance in relation to reporting serious clinical incidents".
And worse, for Harriet's parents, the report concluded that her death was "almost certainly preventable".
The Chief Executive of Nottingham University Hospitals Trust, which runs City hospital, has offered her "profound apologies" for letting the Hawkins' family down.
Yet still Sarah and Jack Hawkins, Harriet's parents, do not feel the hospital has taken full responsibility for their daughter's death. They had to wait more than 18 months for the Root Cause Analysis Investigation Report to be released, and then discovered that, contrary to standard practice, the Trust had not conducted Serious Untoward Incident investigations into any of the 35 baby deaths that occurred at the hospital between April 2014 and February 2017.
So damning were the findings that the Hawkins' are reported to have decided to refer some of the staff responsible for their daughter's care to their professional disciplinary and regulatory bodies and asked the Health and Safety Executive and Crown Prosecution Service to investigate the failings identified in the report.
I am currently running a similarly tragic case involving the death of baby Sebastian Harrold. Sebastian was born at Nottingham City Hospital with severe brain injury in November 2015. He died in January 2016 at just seven weeks' old. An Inquest took place into his death in February 2017, with the Coroner concluding that he should have been delivered earlier and if he had been, it is likely he would have been born healthy.
Despite the narrative verdict and various representatives of the Trust attending the Inquest, it took a further two months for the Trust to offer an apology, and accept that failings in managing the labour caused his death. The case remains ongoing.
Less than six months later, in August 2017, I was instructed by another family in yet another matter involving the maternity department at Nottingham City Hospital, and I am in the process of investigating this case.
Mr and Mrs Harrold routinely tell me that they do not want any other parents to go through what they have. Added to the terrible grief that they and Harriet's parents are trying to cope with, is now knowing that other people have also gone through what they have suffered, and seemingly continue to do so. Similar, avoidable deaths may well reoccur unless the hospital urgently implements protocol to properly learn from its mistakes.
This is in stark contrast to other trusts I work with, who respond in a much more positive light, and are willing to accept responsibility and actively engage in addressing mistakes to prevent them from happening again.
The NHS is currently in crisis, we understand that. But there is little point in publishing reports such as its National Guidance on Learning from Deaths (March 2017) if shortcomings are repeatedly brought to a Trust's attention, and yet fundamental and recommended frameworks are not acknowledged or implemented by Trusts such as Nottingham University Hospital as a matter of urgency to prevent further deaths.
Otherwise, any offer of sympathy or admission of failings simply look like paying lip service after events have occurred, and are worth very little indeed.