As reported by the BBC in this report, concerns have been raised regarding the state of maternity services at Leeds Teaching Hospitals (LTH), with serious allegations of chronic understaffing and substandard care, potentially amounting to clinical negligence.

An experienced clinical staff member, who chose to remain anonymous, described the service as “completely broken,” emphasizing that women and babies are not receiving the care they deserve. Lisa Elliott, a former temporary maternity support worker, described care as “chaotic” and highlighted instances of staff displaying a lack of empathy towards patients.

Elliott, who began working in the hospitals in 2020 and witnessed a CQC inspection in 2024, expressed doubts about the “good” rating given to maternity services. She reported her concerns about staff attitudes but felt they were not adequately addressed. These issues raise serious questions about potential clinical negligence, as the failure to provide adequate care could have significant repercussions for patients.

Prof Phil Wood, chief executive of LTH, apologized to those affected and pointed out the hospital’s role as a specialist centre for critically ill babies. He stressed the difficulty and potential misleading nature of comparing LTH’s neonatal mortality data with other hospitals.

Chris Dzikiti, the interim chief inspector of healthcare at CQC, confirmed that LTH’s maternity services are under close scrutiny. He noted that inspections were conducted last month following concerns from families and ongoing risk monitoring, with the findings to be published soon.

A spokesperson from the Department of Health and Social Care reiterated the government’s commitment to learning from recent investigations to ensure safe, personalized, and compassionate care for women and babies. They emphasized support for trusts failing in maternity care to make rapid improvements and announced plans to work with NHS England to train thousands more midwives.

This situation underscores the critical need for continual oversight and improvement in healthcare services, with legal implications for the trust and accountability to the affected families. The potential issues of clinical negligence call for immediate and effective measures to ensure that the standards of care are met and maintained.

We see too many articles of this nature (frankly any is too many) such as:

• The Ockenden report concerning Shrewsbury and Telford Hospitals, where ‘significant or major concerns’ around the maternity care provided by the trust were identified in a total of 201 deaths (including 12 maternal deaths), 131 stillbirths and 70 deaths during the neonatal period. 
• A major review into maternity services in Nottingham
• And In East Kent

And in August 2024 the Parliamentary and Health Service Ombudsman warned that women and babies are being put at risk after a worrying rise in the number of investigations about maternity care. Read the report here.

If you have been affected by any of these issues, please feel free to contact our specialist team of Medical Negligence Lawyers for free, confidential and informal advice in the first instance.

Article written by Head of Medical Negligence Tom Barnes.

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The review officially began in 2021. However, on 26 May 2022, Donna Ockenden was appointed as Chair of the new independent review into the maternity services at Nottingham University Hospitals NHS Trust. Donna Ockenden is leading a team of experienced doctors and midwifes working in maternity services across England, to review cases of serious, and potentially very serious, concerns regarding the maternity services at Nottingham University Hospitals NHS Trust.

On 15 August 2022, Donna Ockenden called for families who believe that they have been seriously affected by their maternity care and treatment at Nottingham University Hospitals NHS Trust to contact the independent review team. Those families that were approached included those who have suffered stillbirths, neonatal deaths from 24 weeks gestation up to 28 days of life, babies diagnosed with hypoxic-ischemic encephalopathy (Cerebral palsy) and other brain injuries as well as maternal deaths up to 42 days post-partum and other severe maternal harm.

Unlike the independent review of the maternity services at Shrewsbury and Telford Hospital NHS Trust, this review relied upon an opt in process, requiring families to contact the independent review team for their case to be included in the review.

Over the following months, Donna Ockenden and her team have continued to reach out to families in the local community to have their cases included in the review. The review team made contact with Nottinghamshire MPs and City Councillors in the Nottingham area as well as contacting a number of community groups. In addition to this, the review team reached out to staff through the Staff Voices Initiative which was launched in October 2022. The aim of this initiative was to appeal to staff, both past and present, to give an anonymous account of their experiences within the maternity services at Nottingham University Hospitals NHS Trust.

Donna Ockenden and her team have sent out letters to 1,377 families to ask whether they would like their cases to be included within the review, however they only received a response from 360 families. Of those contacted only 27% of white women responded to be included in the review whilst the response rate was much lower for black and Asian women, with only 10% of black women responding and 5% of Asian women. This sample is clearly not a representative sample of the diversity which exists within Nottingham.

This led to the review team and the families requesting that the review be carried out on an opt out basis, as the previous independent review led by Donna Ockenden was.

On 10 July 2023, the Trust’s annual meeting was held. In attendance was Nottingham University Hospitals NHS Trust’s chairman, Nick Carver as well as Donna Ockenden and some of the bereaved families. Nick Carver acknowledged that more needed to be done to gain the trust of the families and communities and he said that he was committed to ‘working collaboratively to plan for an apology on behalf of the board that the families recognise as meaningful’. The Trust pledges for a new honest and transparent relationship.

NHS England has written to the affected families to confirm that the cases will now be dealt with on an opt out basis, with families having to opt out of giving consent for their case to be used in the review. It is hoped that this will give the review team a sample that is representative of the whole community in Nottingham.

Donna Ockenden has commented that she continues to keep her promise to the families to do all she can to ensure that this review is one for all Nottinghamshire families. Donna Ockenden reassured the families in attendance at the meeting on 10 July 2023, that she has seen some positive changes in response to the family accounts, but there is still a long journey ahead.

Donna summarised that what has happened at Nottingham university NHS Trust cannot be fixed overnight. Donna Ockenden and her team will continue to review the cases in preparation of the independent review, and it is estimated that the final report will be published in March 2024.

If you believe you or your child have been affected by the issues described above, please do not hesitate to contact our professional and friendly team, on a confidential and no obligation basis.

Article written by Kirsten Walker

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On 15 September 2019, Baby Wynter Andrews was born in a poor condition following a Category A Caesarean section. Efforts were made to resuscitate and incubate the baby, but sadly Wynter died in her parents’ arms just 23 minutes after being born.

Baby Wynter suffered from a hypoxic ischaemic encephalopathy (a loss of oxygen flow to the brain), which was due to a combination of umbilical cord compression during labour and infection.

Mrs Andrews, aged 33, was deemed as having a high-risk pregnancy due to several health factors. The investigation into the death of baby Wynter therefore found multiple failings and missed opportunities from when Mrs Andrews attended the Queen’s medical centre during her pregnancy, right up to the birth of her baby at 40 weeks.

The inquest at Nottingham Coroner’s court in 2020 revealed numerous failures. These include that staff did not recognise that Mrs Andrews was in established and not latent labour; staff failed to act on high blood pressure readings and that there were four inaccurate and insufficient handovers to colleagues.

It was found that when Mrs Andrews was admitted to midwifery, her blood pressure reading should have been interpreted as mild hypertension, in accordance with NICE (National Institute for Health and Excellence) guidelines. This ought to have led to an obstetrics review and Mrs Andrews should have been transferred to obstetric-led care, with continuous monitoring of the baby’s heart rate. Local guidance states that this transfer should have occurred within 30 minutes of the review.

Further, the cardiography (a machine recording the heartrate) of mother and baby should have triggered an emergency caesarean section. Baby Wynter should have been delivered at 1:35pm, but fatally, the delivery did not take place until 2:05pm.

On 27 May 2022, the Care Quality Commission (CQC) issued a report on the Queens Medical Centre, which stated that their maternity department was inadequate. It was found that in February 2022, there was an overall compliance rate of 62% for mandatory training, compared to the Trusts target of 90%. The CQC also said that the “service did not have enough staff to care for women and keep them safe.”

Bernard Thorogood, the Nottingham Trust’s lawyer, accepted that staff training was an issue but that staff shortages (highlighted as the key reason behind the incident) was a national problem.

District Judge Grace Leong ruled:

 “The catalogue of failings and errors exposed Mrs Andrews and her baby to a significant risk of harm which was avoidable, and such errors ultimately resulted in the death of Wynter and post-traumatic stress for Mrs Andrews and Mr Andrews…My assessment is that the level of culpability is high, where offences on Wynter and Mrs Andrews are concerned.”

The Judge went on to find that there were systems in place, but there were so many procedures and practices where guidance was not adhered to or implemented.

During the case at Nottingham’s Magistrates Court, the Trust admitted that they did not ensure safe maternity care and treatment for Mrs Andrews and her baby. They explained that this was due to a lack of adequate processes and systems to ensure staff managed all risks to their patients’ health and wellbeing.

The Trusts chief executive Anthony May apologised on behalf of the Trust. He said:

 “We are truly sorry for the pain and grief that we caused Mr and Mrs Andrews due to the failings in the maternity care that we provided. We let them down at what should have been a joyous time in their lives. Today, we pleaded guilty and will accept, in full, the findings of the court. While words are never enough, I can assure our communities that staff across NUH are committed to providing good quality care every day…We are working hard to make the necessary improvements that are needed for our local communities, including engaging fully and openly with Donna Ockenden, (chair of the independent review into maternity services at Nottingham University Hospitals NHS Trust) and her team on their ongoing independent review into our maternity services.

Mrs Andrews said that she and her daughter had been failed in the most cruel way, but that her family remained hopeful that the significant fine imposed should send a clear message to the Trust that they must hold patient safety in the highest regard. The mother said:

“Sadly, we are not the only family harmed by the trust’s failings. We feel that this sentence isn’t just for Wynter, but for all the other babies that have gone before her.”

More than 100 families have experienced similar failures at Nottingham University Hospitals, and in March 2022, Queens Medical Centre and City Hospital was served a warning notice by the CQC after they again found several concerns that remained within the maternity department.

Following this action, the Trust has worked to address the failings and has been closely monitored by the CQC to ensure that mothers and babies are safe.

It is truly devastating for the families that have experienced such devastating failures. We hope that this action has brought the failings to the forefront of the Trust to ensure that this does not happen again.

If you feel that you or your baby have experienced poor care which resulted in harm, please do not hesitate to contact our specialist Medical Negligence team who will offer confidential and free initial advice.

Article written by Nancy Tebbutt 

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Ms Ockenden was assisted in preparing the report by an independent team of medical professionals in various areas including obstetrics, neonatology, obstetric anaesthesia, physician, cardiology and neurology.

The review forming the basis of the report is the largest ever inquiry in the history of the NHS into a single service.

Whilst Ms Ockenden clearly acknowledges the difficult and much appreciated work carried out by NHS staff throughout the country, which continues in often challenging circumstances, especially considering the Covid pandemic, she has highlighted some truly shocking failures in the quality of care provided and governance at the Trust.

The report also highlights failures from bodies external to the Trust to effectively monitor the care provided by the Trust.

Background

The Independent review was commissioned by the then Secretary for State for Health and Social Care, the Right Honourable Jeremy Hunt MP in 2017.   The review was prompted by the parents of Kate Stanton Davies and Pippa Griffiths whose daughters had died at the midwifery-led units run by The Shrewsbury and Telford Hospital NHS Trust, as a result of the care they received in 2009 and 2016 respectively. 

As noted by Ms Ockenden:

“This review owes its origins to Kate Stanton Davies, and her parents Rhiannon Davies and Richard Stanton; and to Pippa Griffiths, and her parents Kayleigh and Colin Griffiths. Kate’s and Pippa’s parents have shown an unrelenting commitment to ensuring their daughters’ short lives make a difference to the safety of maternity care.”

The review was originally concerned with 23 families’ cases, as identified by the parents of Kate Stanton Davies and Pippa Griffiths to Mr Hunt.  The number of cases and the scope of the review increased substantially and Ms Ockenden’s review took evidence from 1,486 families, regarding 1,592 clinical incidents mostly occurring between 2000 and 2019.  Although the earliest incident occurred in 1973 and the latest in 2020.

Report Findings

As noted above, the report found repeated failures in the quality of care and governance over the period considered, together with failures of external bodies to effectively monitor the care provided.

The review found repeated errors in care, which led to injury to either mothers or, their babies.  All aspects of clinical care were considered in maternity services.

The review identified continued failures to follow national clinical guidelines in many areas for example, the monitoring of fetal heart rate, maternal blood pressure, management of gestational diabetes or resuscitation.

The report presents specific incidences including those of Kate Stanton Davies and Pippa Griffiths and the strikingly similar circumstances of prior cases.

There were delays within the Trust to escalate matters to more senior specialists and a failure to work collaboratively across disciplines.  The results of these systemic failures were truly tragic and led to serious medical conditions such as sepsis, hypoxic ischaemic encephalopathy and death.

The report highlighted a fear of midwives to express their concerns to consultants within the Trust, resulting from poor working relationships.  This culture of fear was combined with staffing problems and a lack of training.  These difficulties were played out in front of families, which put additional stress on parents at times when they were at their most vulnerable.

The review detailed repeated circumstances where families were not treated with the sympathy or, compassion they should have expected.  With clinicians unprepared for follow up discussions, not dealing appropriately with complaints, giving inaccurate information and even blaming the parents themselves for the outcomes.

Within the Trust there was an emphasis on promotion of natural birth, with a reluctance to perform caesarean sections.  This directly resulted in babies dying during or, shortly after birth or, alternatively being left with catastrophic, life-long heath conditions.

The review’s consideration of clinical governance processes shows that investigatory processes were not followed to a standard that would have been expected. As noted by Ms Ockenden:

“The reviews were often cursory, not multidisciplinary and did not identify the underlying systemic failings and some significant cases of concern were not investigated at all. In fact, the maternity governance team inappropriately downgraded serious incidents to a local investigation methodology in order to avoid external scrutiny, so that the true scale of serious incidents at the Trust went unknown until this review was undertaken.”

This meant that there were missed opportunities to learn from the incidents occurring within the Trust with continued and repeated serious mistakes and omissions, leading to further avoidable injuries and deaths to Mothers and babies.

Figures

The report graded the care provided in four categories as follows:

0, Appropriate, Appropriate care in line with best practice at the time

1, Minor concerns, Care could have been improved, but different management would have made no difference to the outcome

2, Significant concerns, Suboptimal care in which different management might have made a difference to the outcome

3, Major concerns, Suboptimal care in which different management would reasonably be expected to have made a difference to the outcome

The review listed five major incident categories; Maternal death, Stillbirth, Hypoxic Ischaemic Encephalopathy, Neonatal death and Cerebral Palsy/Brain damage.

The review found that for the care provided in categories 2 and 3, and consequently avoidable outcomes, there were Nine maternal deaths, 131 still births, 70 neonatal deaths and 94 cases of brain damage.

Future Developments

The report identified more than 60 specific Local Actions for Learning for Shrewsbury and Telford Hospital NHS covering nine areas and another 15 Immediate and Essential Actions for all maternity services in England.  The aim of these actions is to improve all maternity services in England, including financing a safe and sustainable maternity and neonatal workforce and ensuring appropriate training for all those involved in maternity services.

The report acknowledged the recent announcement of £127 million by NHS England for maternity services but noted that this was significantly short of the £200-£300 million recommended in June 2021 by the Health and Social Care Select Committee.

Comment

The individual mistakes identified within the investigation are, sadly, nothing out of the ordinary and are regularly encountered in our work.  What is striking, however, is the shear scale of the problem and the number of families affected, suggesting a significant cultural problem within the trust.

If you have been affected by failings in maternity care, then please feel free to contact us for free and informal initial guidance on the options available to you.

Article written by Medical Negligence Solicitor Adam Lloyd

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Kerry Hudson, Employment Solicitor warns that there is a risk ‘mothers to be’ on furlough may be tempted not to notify their employers of their pregnancy, partially because they think they may get receive more money on furlough, or if they are worried about redundancies, fears of being discriminated against, or even simply because they believe they do not have to tell their employers they are pregnant. 

However, ‘keeping mum’ could compromise their position which would otherwise have been protected.

Pregnant employees have several safeguards under legislation such as:-

• Under the Equality Act 2010 which prohibits discrimination against employees because of the “protected characteristic” of pregnancy and maternity during the “protected period”.

• Employment Rights Act 1996 which sets out rights to health and safety, time off for ante-natal care, maternity leave and unfair dismissal.

• Maternity and Parental Leave etc Regulations 1999 which set out a woman’s entitlement to maternity leave and the notification requirements.

Legally, employees are obliged to notify their employer they are pregnant 15 weeks before their due date. At this point, the employee can tell their employer when they wish to stop work to have a baby and the day they want their statutory maternity to start.

Cases of employers being unsupportive or uncooperative with employees who are ‘mums to be’ have thankfully become few and far between.

In light of this, Kerry has provided an insight into the rights of pregnant women working in the pandemic and what protections they have against discrimination or unfair treatment.

Once the employer is informed by the employee that they are pregnant, the employee is then protected against unfavourable treatment because of pregnancy-related discrimination.

If informing an employer by the deadline is not possible for reasons such as the employee was unaware of their pregnancy, then the employer must be informed as soon as possible.

Once told of their employee’s pregnancy, an employer will be required to carry out a workplace assessment to ensure the workplace is safe enough for them to work in, when they are return for furlough.

“There is a risk that women on furlough may neglect telling their employers they are pregnant simply because they are not aware of their obligation to do so or because they are concerned that they will be treated unfavourably or even be first in line for redundancy –especially at a time when redundancy rates remain high across the UK. 

“However, this could not be further from the truth. In fact, employees who tell an employer about their pregnancy are actually more protected than their co-workers.

“Under current legislation it is against the law to discriminate against anyone because of being pregnant, so by failing to inform an employer of a pregnancy, employees are doing themselves a huge disservice as they’re essentially relinquishing their right to be protected under the legislation .

“If anything, an employee who is pregnant has enhanced rights when it comes to selection criteria for redundancy.”

With around 16% of the UK workforce still on furlough, Kerry has also warned mums to be that failing to notify their employer puts them at risk of not being able to access all their entitlements. 

Contact us for Employment Law advice

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Instead of receiving her normal wages, she will receive a Statutory Maternity Payment, or an enhanced maternity payment if the contract of employment provides for one. Otherwise all of her other benefits remain the same, so provided that she had them before her maternity leave, she would also be entitled to receive her:

• Private health care
• Life Assurance
• Company Car
• Bonuses
• Pay Rises

However, a question arises where an employee has a Defined Contribution pension schemes. “Defined Benefit” or “Final Salary” pensions sit outside of the scope of this problem given that the pension will be calculated depending on the employee’s final salary rather than the value in the pot and therefore the value of input by the employer is somewhat of a moot point as contributions will need to be maintained to support that scheme.

Technically a pension is a contractual benefit, therefore under the Maternity and Parental Leave Regulations the employee would be entitled to receive them as normal. Under UK Provisions a payment is only due where the employee qualifies for a maternity payment in the first instance; therefore no payments are required where an employee does not qualify for maternity pay, or where they are on unpaid Additional Maternity Leave.

However, it would be unreasonable to suggest that she should continue to make payments at the same value as she had been under her full employment as to do so would be likely to wipe out the value of any maternity payment. Section 75 of the Equality Act therefore states that any contributions made by the woman must only be in relation to the sums that she receives at that time. So therefore a woman on maternity leave will only ever have to contribute 5% of her maternity pay, which is presently £6.44.

So far, pretty straightforward; however, what is the employer’s contribution? Well it will first and foremost depend upon the terms of the Pension; if the employer does not contribute in the first place then it will be suddenly expected to contribute thereafter. However if, and for the purpose of this article assuming that the employer does, contribute a percentage of the employee’s salary to the scheme the it’s obligations will continue. IN SUCH CASES it would be reasonable to assume that the value of the contributions would be the relevant percentage of the Employee’s maternity pay. Unfortunately that may be incorrect, as any modified term in her contract of employment must treat an employee on maternity leave as if she is not on maternity leave. It therefore follows that if an employee contributes 5% of her maternity pay then the Employer would have to provide whatever percentage in respect of the employee’s full salary.

There are 2 schools of thought, one as set out above that the employer should continue to maintain their level of contributions, as set out above, and as seems to be implied by and the other which the government appears to be favouring at the moment, although the most recent BIS and HMRC Guidance remain silent on the issue, is to treat the pension contributions as being part of the remuneration, thereby providing that the contributions will vary dependent upon the value of the sums paid to the employee. Unfortunately there is no definitive authority on this point and we await a case that challenges the issues.

Further, the European Law provides us with authorities in respect of the time in which the pension benefits must be provided. The cases of Boyle and Sass appear to suggest that any benefits must be for the duration of the full period of maternity leave, and should not stop at the end of the Ordinary Maternity Leave as they presently do in the UK. Again we await a UK authority on this.

In Practical terms

Practically, what does this mean for employers? Well, if you do not presently provide any contributions to pensions then you will be safe to carry on as you are, however, beware that the law changes from October 2012 and employers will be forced to contribute to their employees pensions.

Equally, if you are supporting an Final salary pension scheme then you are likely to have to keep up the contributions in order to maintain the existence of that pension fund.

In the event that you are providing a pension where the employer makes contributions, it is often best to:

• a) Offer a payment holiday for the employee during the duration of the maternity leave period, and inform them that they can make increased contributions at a later date if they wish to do so. Given that statutory payments are low, many employees will be grateful of the chance to take that opportunity and thus also allowing the employer to do the same.
• b) Check the rules and terms of your scheme to see what you are contractually obliged to pay, to see what contributions you will pay, if any.
• c) Consider reducing the pension payments to a value equal to the employee’s contributions. However, you should take independent legal and pensions advice before doing so.

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