MP to lead 'improvement board' after maternity failings

An MP who is the government's first national maternity adviser will chair a board to oversee improvements at an NHS trust after a damning review into its maternity failings.

The review into Nottingham University Hospitals (NUH) NHS Trust, published on Wednesday, said "deeply embedded systemic failures" led to deaths and avoidable harm to babies and mothers.

NUH said the Learning and Improvement Board was to be chaired by Labour MP Michelle Welsh, whose own son William was born initially unresponsive after delays by maternity staff.

Anthony May, the chief executive of the trust, called the review's publication a "watershed moment" and said it was important to have oversight of its findings.

About 2,500 families and more than 800 staff members contributed to the review, which began in September 2022.

The independent maternity review, led by senior midwife Donna Ockenden, concluded there were "potentially avoidable" outcomes for mothers and babies in 520 cases.

It also found that different care may have altered the outcome for 260 babies - 155 who died and 105 who suffered serious brain injury due to substandard care - the review team told the BBC.

The review found the harm was rarely the result of a single issue or specific failing but was linked to multiple factors, including failures in monitoring babies, poor interpretation of heart monitoring, a failure to recognise babies were in distress during labour and a failure to escalate some cases to senior doctors.

Concerns of women were often dismissed and minimised, and staff described racism and "racist attitudes towards black women labelled too loud, too demanding".

Leaders at the trust were aware of serious issues in its maternity department going back to "at least 2010", but failed to take action, the review found.

The report also identified a "bullying and toxic" workplace culture, which prevented staff members from speaking up.

NUH was given a list of actions it must now take to address the failures found by the review team.

Those actions included urgent improvements to risk management and monitoring, improving neonatal safety and care, improving psychological support for families and improving governance, leadership and accountability.

Sherwood Forest MP Welsh was appointed as the government's first maternity adviser in May.

During the birth of her son in 2020, she was repeatedly told not to come in to the hospital.

He was then born not breathing and even when revived, she was told he was likely to be deaf and have learning difficulties, which turned out to be inaccurate.

She said: "The findings of the independent maternity review reinforce the urgent need for change in our maternity services.

"For that reason, I have agreed to chair the NUH Learning and Improvement Board.

"I acknowledge the suffering experienced by the families at the heart of this review, whose courage in speaking out has brought to light the desperate need for change.

"Having campaigned for improvements in maternity services for the past five and a half years, I am committed to working collectively with families, staff and partners to ensure lasting improvements are made."

Health Secretary James Murray said the revelations of the review were "chilling" in an address to the House of Commons on Wednesday.

Murray also welcomed the appointment of Welsh as chair of the improvement board.

"This is a significant moment and recognises Michelle's tireless efforts campaigning to improve maternity and neonatal services, delivering real change for all families," he said.

The Learning and Improvement Board will be supported by two additional groups, one representing families and one representing staff.

Having led the review, Ockenden will co-chair the group representing families, alongside a family member.

She said: "I am so pleased to be remaining in Nottingham to support the ongoing perinatal improvement journey at NUH.

"The development of the Learning and Improvement Board fulfils a promise made to families that there would be continued scrutiny and improvement of maternity services at the trust.

"Its creation is also important to the more than 800 current and former staff at the trust who have engaged with the review.

"I am so glad that this is also an opportunity for their voices to continue to be heard."

The families affected by NUH's failings said the actions must be treated "with the utmost seriousness" and called for a statutory public inquiry across England.

Kim Errington's son Teddy was a day old when he died at Nottingham City Hospital in November 2020.

An inquest into the baby's death found there were "undoubted failings" in his care.

Errington told the BBC she had been "fighting for five and a half years" and believed an improvement board was not enough to "solve the problem".

"I can't help but be cautiously sceptical.

"I know that these things have to be put in place but the bottom line is we need a public inquiry to get to the real root of these issues and prevent it happening again.

"Anything that can happen alongside that, great, but don't do it as a standalone thing," she said.

NUH has been under close scrutiny since before the review began, due to maternity failings, and has paid out £117m in compensation, as well as being handed two record fines following prosecutions over the deaths of babies.

The trust said the new board would provide an "independent check and challenge on the delivery of improvements".

Chief executive of the trust May said the publication of the review was an "important milestone in a journey that must continue".

He said: "It is very important that we have robust, independent oversight of the implementation of the review's findings.

"We are committed to a comprehensive and sustained response to every action.

"Two years ago, we made a public commitment to ensure continued scrutiny of our maternity services, and this board is a key part of delivering on that promise.

"In the coming weeks, we will publish a detailed action plan setting out how every action will be addressed, with clear timescales and named accountability.

"We will continue to involve families and staff in shaping our response, and in holding us to account.

"We will work closely with the Learning and Improvement Board, NHS England, our regulators, commissioners, local families, partners and maternity experts to ensure improvements are delivered and sustained."

The trust said the board's terms of reference would be developed in partnership with families, staff and stakeholders and a first meeting would take place later in the year. It added progress updates would be shared publicly on a regular basis.

Additional reporting by Verity Cowley

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