The most extensive inquiry into NHS maternity care, prompted by the deaths of infants including Wynter Andrews, has revealed systemic failures within Nottingham University Hospitals NHS Trust (NUH). The investigation gained momentum through collaboration between bereaved parents Gary Andrews and Jack Hawkins, who connected via messages.
Wynter Andrews died 23 minutes after delivery by Caesarean section on September 15, 2019, at Queen's Medical Centre. An inquest determined her death, caused by a loss of oxygen to the brain, could have been prevented with earlier intervention. Sarah Andrews, Wynter's mother, had been admitted to the hospital six days after initial contractions. The inquest heard the maternity unit was understaffed and patient history was not adequately handed over between shifts, contributing to missed warning signs.
Coroner Laurinda Bower noted that multiple missed opportunities to save Wynter's life had been identified. A 2018 letter from midwives to NUH bosses had warned of potential disaster due to staffing levels, a prediction the coroner stated was realized with Wynter's death. In January 2023, NUH pleaded guilty to care failures in a criminal prosecution brought by the Care Quality Commission (CQC), resulting in an £800,000 fine.
Two fathers, Gary Andrews and Jack Hawkins, whose children also suffered adverse outcomes, became instrumental in bringing the scale of the scandal to light. Their initial contact, a message from Gary to Jack, initiated a chain of communication that connected hundreds of affected families in Nottingham.
The inquiry, led by Donna Ockenden, has reviewed thousands of cases and highlighted ongoing concerns about maternity care. The investigation has uncovered a pattern of repeated failures, including missed opportunities to escalate concerns about fetal wellbeing and inadequate responses to maternal emergencies.
The scale of the scandal has led to broader calls for reform within the NHS, focusing on improved safety protocols, staffing levels, and accountability for care failures. The collaboration between families, spurred by the initial connection between two fathers, has been crucial in driving these changes and seeking justice for those affected.