'Obvious neglect' in baby's death at Queen's Medical Centre

A baby girl who died 23 minutes after being born may have survived if "multiple missed opportunities" were spotted by staff, an inquest found.

Wynter Andrews was delivered by Caesarean section on 15 September 2019 at Nottingham's Queen's Medical Centre.

Nottingham Coroner's Court heard concerns over the conditions of the baby and mother were not acted on.

Assistant coroner Laurinda Bower said it was "a clear and obvious case of neglect".

The inquest heard Sarah Andrews had been admitted to hospital on 14 September, six days after initially suffering contractions.

Midwives had previously told the hearing the maternity unit was "busy" when the patient arrived, with information on the patient's history not properly handed over to other staff at shift changes.

"The early care of [Ms] Andrews was littered with departures from local and national guidance which led to multiple missed opportunities to seek earlier medical care for baby Wynter," Ms Bower said.

A doctor seeing Ms Andrews the following morning did not pick up on concerns raised by midwives over a trace examination of Wynter, or worries about a possible infection, and it was not until 13:35 on 15 September that a Caesarean section was requested.

Ms Bower said "repeated failures by all staff" to consult notes was "perpetuated by incoming professionals who relied upon an inadequate and insufficient handover of the patient situation", leading to risk factors "being omitted from their clinical decision making".

Wynter was delivered "in poor condition" at 14:05, with the umbilical cord "wrapped tightly around her leg and neck", and efforts to resuscitate her were abandoned 23 minutes later.

Ms Bower said: "If [she] had been delivered earlier, it is likely that her death would have been avoided."

The medical cause of death was given as a lack of oxygen to the brain caused by a combination of infection and "umbilical cord compression during labour".

Ms Bower said "systemic issues" contributed to the neglect of Wynter, adding the unit was so short staffed midwives were looking after a number of high-risk patients simultaneously.

She said that meant Ms Andrews "was not afforded the care and attention that she clinically required".

As well as staff shortages, the trust "had failed to create an environment where professional challenge was promoted and encouraged", both of which Ms Bower said "led to corners being cut and unsafe practices prevailing within the unit".

Ms Bower issued a prevention of further deaths report, which will be referred to the Care Quality Commission and the Healthcare Safety Investigation Branch.

She cited a 2018 letter from midwives on the unit to bosses at Nottingham University Hospitals NHS Trust (NUH) outlining concerns over staffing levels as "the cause of a potential disaster".

"[It] makes for troubling reading, as the grim predictions of a potential disaster were indeed realised some 10 months later when Wynter died as a result of the unsafe practices warned about by midwifery staff," she said.

"Wynter was a victim of the trust's failure to adequately address the concerns that clearly existed many months before [Ms] Andrews' arrival at the hospital."

Following the conclusion of the inquest, a statement on behalf of the Andrews family called for Health Secretary Matt Hancock to start an inquiry into the trust's maternity services.

"We know Wynter isn't an isolated incident - there have been other baby deaths arising because of the trust's systemic failing," the statement said.

Mandie Sunderland, NUH's chief nurse, apologised for the failings in Wynter's care, adding the trust is "determined to learn from this experience".

"[We have] already implemented a programme of work to ensure that we do everything in our power to ensure that this does not happen again," she said.

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