All language subtitles for Maternity.Broken.Trust.2024.720p.WEBRip.x264.AAC-[YTS.MX]

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NEWS REPORTER:
'An inquiry into the deaths

'of babies in Nottingham
is expected to become

Official YIFY movies site:
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'the biggest maternity investigation
in NHS history.

'Around 1,700 families
who received maternity care

'from the Nottingham University
Hospitals NHS Trust

'are to have their cases reviewed.'

NEWS REPORTER: 'The review,
led by midwife Donna Ockenden,

'will find out
whether dozens of babies died

'or were seriously injured
because of poor care.'

NEWS REPORTER: 'Around 100 people
gathered here in West Bridgford

'to hear the latest
on the investigation

'into maternity failings

'at both the Queen's Medical Centre
and City Hospital.'

Good afternoon, and...

thank you so much for coming,
and welcome.

My name's Jack Hawkins.

It's bittersweet
seeing so many people here.

I don't really know what to say,

because my daughter didn't survive
routine health care.

I'm Sarah Hawkins.

I'm a mummy
to two beautiful daughters.

Harriet should be seven,
and Lottie is four.

Hi, everybody, I'm Natalie.

My son Kouper never opened his eyes.

He never moved a muscle.

He never fed.

Wynter was a perfectly healthy baby.

There was no reason for her to die.

I'm a harmed mum,

and the problem is it doesn't stop

because we're still here
eight years on.

What we're most worried about
is that harm is ongoing.

NEWS REPORTER:
'Donna Ockenden is calling for

'more families to come forward,

'or her inquiry risks
being a failure.'

This is a call to arms.

We must now all speak to Donna,

to get the justice we deserve.

Thank you.

APPLAUSE

PIANO PLAYS GENTLY

HE PLAYS
'WHERE IS MY MIND?'

There you go.
Oh, thank you.

PIANO MUSIC
CONTINUES

SARAH: 'So, I met Jack in 2008.'

We both worked at the hospital
at the time.

I was a physio,
and Jack was one of the doctors.

And he told me a really bad joke.

JACK: 'I had a bad shoulder,

'and I was trying
to get you to fix it.

'You were, like, so dismissive.'
THEY LAUGH

Shoulders weren't my speciality.

Yeah, but still,
you know, read the signs.

THEY LAUGH

We got married November 2013.

I think it was less than a year
after we got engaged.

It was ace, wasn't it?
Yeah.

Often spoken about.
Yeah.

We're both one of four,

then we thought we'd have
four kids, country house, dog...

Did we? I thought we said three?

Oh, no, because you can't have
an odd number.

Fair enough.

PIANO MUSIC
CONTINUES

BIRDSONG

SARAH: Lottie, would you like
cordial or a Fruit Shoot?

Cordial.
Yeah, in your Charlotte cup?

You can do your work, we do ours.

JACK: Oh, you gonna do some work?

Can you hear it?
Mummy, just a little louder.

Is that OK?
Yeah.

Not too loud?
Not too loud. OK.

So there's... This is the timeline
of what happened in our care.

Yeah, yeah.
I can put that file on the chair,

and I'll have the computer,
if you don't mind writing it?

No. I'll write.

NEWS REPORTER:
'Baby Harriet Hawkins was born dead

'at Nottingham City Hospital
on the 17th of April 2016.

'She died as a result
of a mismanaged labour.

'Harriet's father, Jack,
is a hospital consultant.

'Her mother, Sarah,
is a senior physiotherapist.

'Both worked for
the hospital trust responsible

'for the death of their baby,
their first child.'

Do you want to just
use your normal pen? Yeah.

NEWS REPORTER: 'Since that day,
the couple have campaigned

'to force the Trust
to acknowledge it made mistakes.

'Mistakes which they believed
had been covered up.'

So, let's just be clear,

what do you think
that Donna wants from us?

Well, I think she needs to know,
Donna needs to know...

..basically all of Harriet's story

and what went on
during my pregnancy and birth.

Her due date was 11th, wasn't it?

Due 11-4-16.

I started having contractions
through the night,

so they never stopped
over the whole six days.

Six to nine mins.

'It's been nearly eight years
since Harriet died, and, erm,

'yeah, I remember
every second of it,

'like, it feels like
it was yesterday.'

Then that evening,
that's when we did go in.

That's the first time
that they suggested

this was latent labour,

and that was in our heads then?

Yeah.

I made 13 contacts
with the hospital.

They just weren't listening to me
when I was asking for help.

On the 16th,
they told me to come in...

..and I said, "Will I need an
epidural because I'm not managing?"

And then she said,
"Oh, no, you're too early for that,

"but why don't we give you...
some diamorphine?"

Which is ridiculous
when you think about it,

a massive dose of opiates.

And so,
without the doctor seeing you,

you had ten milligrams
of diamorphine.

Codeine.

We didn't know this at the time,
did we?

We found this out afterwards.

Codeine, 60,
and one gram of IV paracetamol.

Yeah.

Which is massive, isn't it?
It's huge.

I've never... I've...

Just cannot imagine giving
those doses of those medicines

and letting anybody home.

'You know, having these six days
of just begging for help

'and no-one agreeing with me
or, you know,

'basically, I felt like a fraud.'

And then on the 17th...

..phone call to the labour suite,

and that was
the worst phone call ever. Yeah.

She was horrible.
Yeah.

'Er... That was...

'Oh, that lady was just horrific.

She said, "I'm sure you're not
in established labour,

"so stay at home."
So I got off that call,

and I was just
lying on the sofa, crying,

and then something started
to hang out of me.

That was ten to four.

We jumped straight in the car
to the hospital.

I walked in,
there were three staff.

One of them was the midwife
I'd had the phone call with.

She just shouted
down the corridor to me,

"Is it still hanging out of you?"

So then I just burst into tears
because I'd been in labour

for, like, six days,
and I was exhausted.

Then that midwife said, "Does it
feel like you need to push?"

And I was like, "Yeah."

Then she said,
"Oh, I can see the baby's head.

"The baby's about to come.
You're too late for pain relief."

'She had said, "I'm just gonna
check the baby's heart rate."

'She struggled to find it.

'So then they called for the doctor,
and then the doctor scanned

'and said,
"I'm sorry, your baby's dead." '

'I think I just wanted to die.'

'Yeah, you know, like...

'I was asking for help.'

I think I'd convinced myself
it was a boy.

I think we had. Yeah.
Yeah.

I quite liked Arthur.

I remember when we saw her,
I was like,

"Oh, she definitely looks
like a little Harriet." She does.

Harriet Ella Rene Hawkins.

She was perfect, wasn't she?

Hi, Avi, how are you?
Good to see you. And you.

Hi, Avi, nice to see you again.

'I've had multiple therapists
at different times

'for slightly different reasons.'

Thank you for coming again.

We've never seen anyone...
Together? ..together.

I see.
No. In therapy.

We're here because you've suffered
the unexpected death of your child

and then found yourselves

in a years-long fight to be heard.

Yeah, erm...

'Yeah, absolutely.

'The toll that has taken on us
needs some sorting out.' 'Mm-hm.'

'After Harriet died,
for days, for weeks,

'we expected them
to come forward to us and say,

' "Right, this is the death
of a completely normal baby.

' "What has happened here?"

'But they didn't do that.

'It was, "Nothing's happened.
Nothing to see here."

'And hushed,
and, "These things happen." '

They just refused
to even have a conversation

about what might have happened,
what else might have happened.

Do you think it's hungry?
Oh, is it?

Do you want some food, do you think?

Whoo!

Right, monkey.

I'm gonna need you to help me
Sellotape something on the wall.

You look like a professor.
JACK CHUCKLES

'They had done
their own investigation

'into Harriet's death.

'We didn't know about...
they were even doing this.

'It was completed,
it had the wrong place of delivery.

'In the end,
it said no faults by NUH

'and then they said
death was infection.

'As in, they tried to blame
Harriet's death on infection.'

We were saying
we don't agree with that at all.

And they said, "But this has gone
through six other consultants

"and four senior midwives."

Now, to us,
that's a chunk of the department

thinking that
this report was good enough.

And bearing in mind
we'd been blowing the whistle

all the way through this
and saying something's not right.

Also remember, I worked there.

We hoped that meeting
the Chief Executive

and the Medical Director
in January 2017,

they would go, "Crikey, yes, OK.
"Something's gone very wrong here."

'But then it became very clear
that they...

'they were interested
in maintaining

'the position of the hospital.'

I'm just gonna put some red here
for organisations. Yeah.

'And it would have
made a big difference, I think,

'if they'd said,
"This shouldn't have happened."

'Instead of that,
we were completely cast out

'and ignored and vilified.'

'We've got these emails
from the Trust,

'and they have written emails
about us,

'like, "When can we sue them
for defamation?"

' "They haven't had to fight
as hard as they have.

' "Their media releases
are full of lies." '

I feel like they're trying
to make me go crazy,

like, after all those years,
you know,

there's still that thing of...

them blaming us.

Cos I do feel like
that was one of their tactics.

Like, to make us feel
like we were grieving and...

..crazy.

And we were broke.
Well, I was broken.

'And, you know,
we were senior clinicians,

'so what else have they done
to other people?'

'We knew we cannot be the only ones.

'We searched the news.

We found a news report
of a young lad

who died two years before Harriet,

because at caesarean section,

they cut one-inch deep
with a scalpel into his head.

JACK: "Following the inquest,
Dr Stephen Fowlie, Medical Director,

"said, 'The pathologist concluded

" 'that this extremely rare
complication of the caesarean

" 'caused Carson's death.

" 'It will never be known
whether had this not occurred

" 'Carson would have survived.' "

Makes me so angry. What on earth?

'After that, my life, for years,

'was just
scrolling social media 24-7,

'just trying to find someone
with a dead baby.

'Which takes a toll.'

'We set up a Facebook page.'

It started off
with a small group of us,

and then it jumped to 12,
and then 20, and then 50.

Yeah, there's hundreds of us now,

talking to each other,
sharing information.

The most horrific community
you could want to be part of,

but at least
there are other people saying,

"Yes, your experience is mine."

'I feel a deep sense
of responsibility

'for these other families.'

Who else is coming?

Just us, I think.
Is this it?

The thing is, every time we meet,

there's at least one more bombshell
from one of us that we found out.

I don't think a week's gone by
where there hasn't been something

quite shocking that's come to light.

I mean, what, we're in 2023 now,

and we think
there's still more to come. Yeah.

When Sarah had to go back
and have a bladder scan -

that they should have done

a couple of weeks after
Harriet's death and they forgot -

they then sent us
to antenatal clinic with a letter

saying, "Please make sure
your bladder is full

"so we can scan your pregnancy."

I get that,
and I don't have a bladder.

"Yeah, don't have one,
so what do I do?

"Can't come with a full bladder
if I don't have one."

They still don't even know,
even to this day.

I'm eight years on now, just,

because it's obviously
just Max's birthday.

They still don't even know

which of my ureters
they chopped off as well.

They chopped off the bladder
and one of my ureters,

and the urologist says one,

and the two doctors
that did it to me say another.

I don't even know
which body parts I've got.

When Wynter died and we were
in the bereavement suite,

the governance team come to us
with a letter, didn't they?

And I had to point out
it's not our son,

it was our daughter, you know?

And they're like,
"Oh, we'll go and change that."

So those little details,
you know. It's just...

You're going into the room
of a family whose baby's just died.

You go in there knowing if
it's a girl or a boy, don't you?

You would if there were
any consequences. Well...

"It's the families
that don't remember",

I got told at inquest.

Was that the coroner?
The coroner.

I'd argue the opposite.

She favoured
the NHS's version of events

because the family had been
through something so traumatic

that they can't possibly remember
in what order those events happened.

It's exhausting, isn't it?

NATALIE: Kouper was born.

He didn't cry. He barely cried.

And I knew then
that something was wrong.

He was born at quarter to two
in the morning,

and he was discharged at
half past three in the afternoon.

Even though I'd raised concerns
that he'd never opened his eyes,

he never moved a muscle,
he never fed.

All I got told by midwives
was he was my fifth child,

and I should know
how to wake a baby and feed him,

and to go away and do it.

He died at quarter past two
in the morning

while we were asleep.

We rang 999
and was told to do CPR.

So I got my son on the floor
and did CPR the best I could.

When the ambulance crew
and everybody arrived,

me and my husband were arrested.

I wasn't allowed to sit with my son
in the ambulance

on the way to the hospital,
I had to sit up front.

I wasn't allowed to see him,
hold him or touch him.

The hardest thing was seeing my kids

watch their mum being taken away
for killing their brother.

SHE CRIES

'Some of us have fought for years
to get our medical records

'because we believe some of them
are incorrect or incomplete.

'At least we worked
at the hospital,

'and that's how we can help others.'

My problem is,

the memory that I have
of Kouper's state of health

is completely different to what
the coroner was told at inquest.

JACK: I'm gonna make some notes.

Erm...

Is it the 17th?
Yeah.

So, in here is everything...

Wow.
..right up to the present day.

Wow.

There is too much here to sort out.

They think by landing this on
my doorstep all together in one go,

that I'm just going to look at it
and go "Ugh."

Nicely redacted, your info.

Do you know what it says
about your son?

What was under there?
God knows.

The police officer that was involved

came and brought
Kouper's belongings back.

She said,
"So, has anybody rang and told you

"that he had two collapsed lungs
on his MRI scan?"

This is the police telling you?
Yeah.

So I went mad, rang the hospital.

She said to me, "Well, the reason
why I didn't tell you

"is because you collapsed his lungs
doing CPR,

"so you killed your son."

They made me believe
that he had no chance

of being brought back to life...
Because you...

Because I collapsed his lungs
doing incorrect CPR.

We was just told that we was
being, erm, arrested under caution

and he had to have an MRI scan,

and we couldn't see him

until they could make sure that
we'd not structurally damaged him.

It's only been since inquest

when the doctor that did
the postmortem stood up and said

that he felt that one of his lungs
was collapsed pre-birth,

or during labour,

that it hit me
that I hadn't done it.

WHISPERS: Fuck me.

On Kouper's shelf.
Yeah.

This one.
Yeah.

You can't really see it very well
cos it's glass,

but it has got his picture
engraved on it.

Oh, let's see.

Oh, Kouper.

It's that picture in there.
Yeah.

That picture was taken
literally minutes after he was born.

All we've ever done
is speak the truth,

yet we're always being told...

Well, we was told at inquest
it's not the truth. Yeah.

And that hurts because telling
a family who have suffered...

You've misremembered.
..such a tragic thing

that we can't possibly remember
what way it happened.

You will never forget
what way it happened. No.

I rang the hospital 17 times

and was repeatedly told
that there was no beds.

David had starved of oxygen

and passed away inside me.

We were told that she probably
wouldn't survive the birth.

We decided to end the pregnancy

because we didn't want
our daughter to suffer.

We found out the test results
came back completely clear.

You can't imagine that feeling.

The consultant says, "Well,
you could've miscarried anyway."

I'm still going
to have to give birth

to a baby
that's gonna come out silent.

And literally, your dreams
are shattered in an instant.

I wonder how my sleep will be
tonight.

Interesting dreams, I presume.
Interesting.

NEWS REPORTER: 'Donna Ockenden,
the senior midwife,

'recently reported on the
maternity scandal in Shropshire,

'which uncovered more than
350 cases of serious harm.'

NEWS REPORTER: 'Donna Ockenden
is leading the independent review

'examining dozens of baby deaths
and injuries,

'and mothers
who suffered serious harm

'at the Queen's Medical Centre
and Nottingham City Hospital.'

SARAH: 'It's been a very long fight
to get this review to happen.

'We campaigned
for Donna to get here.

'Now we just need
for those responsible

'to be held to account.'

DONNA OCKENDEN: All reviews will get
this multi-professional assessment,

and they'll be graded.

Zero if the team
feels that care was appropriate,

to grade three
if there were major concerns

in which, in all likelihood,

different care
would have changed the outcome.

The original families
who campaigned so hard,

they all met the terms of reference
and they were within the review.

So that room?

'I think I would like
just to sort of refresh

'what it is that you are doing.'

'We will consider all of the
evidence that is possibly available.

'Medical records
are a large part of that.

'Family testimonies,
governance and risk information,

'so it all comes together
in one big jigsaw.

'And, you know, family voices.'

I know you know
this runs absolutely central,

right through the review.

I guess, after meeting
all the families... Yeah.

..what I really want to know
is when...

when, you know, substantive change
is going to be made

and when care
is going to be safe again at NUH?

OK, I am seeing
a definite intention, erm,

that families will be listened to

and that what families say matters.

With that in mind,
families want to understand

what an apology would look like.

A proper apology, not a
"we reiterate our condolences."

OK. OK.

Erm, just talking specifically
about Harriet now,

that we've given you, erm,
evidence that we have and stuff,

and whether there's anything more
that we can give you

to develop her case and...?

What would be really helpful
to my review team

would be a timeline
from your perspective.

You know, what you want the review
to understand and highlight

is the huge amount of effort
that you put into,

erm, trying to tell the Trust
very soon after Harriet died,

erm, about the problems
that they had.

And then, as you've explained to me,
how compounded your grief was

when you kept being pushed away,
pushed away,

"there's nothing here to look at."

You wrote to X
on such-and-such a date.

You wrote to Y, you wrote to Z.

You wrote to A, you wrote to B.
Yeah.

That would be extremely helpful
to my team.

These are all the emails
that I've found. Wow.

So we just need to print out
the emails from that.

Yeah, so look at these emails
all to the medical director. Yeah.

And that meeting,
I mean, it's all recorded,

but we totally
blew the whistle there.

And this is the stuff for Donna...

Yeah.
Because it is...

It describes a clear timeline
of people being told

and failing to respond
in a way that changed things.

I mean, look at this.

"We have considered all relevant
incidents since December 2015.

"To date, ten of these cases
have been reported as SIs."

JACK: There are different categories
of incidents.

You have standard incidents,
and then serious incidents, or SIs,

which have to be investigated.

Any serious incident at a hospital
is reported

to the Department of Health,
who assess the safety of a hospital.

At Nottingham,
they invented a whole new category

called a "high-level incident",
which does not get reported.

And the medical director
has downgraded so many cases,

and that's frightening.

'I'm used, I guess,
to people taking me seriously.

'To have that so fundamentally
ignored is difficult.'

"We do not consider the threshold
for such referrals have been met."

It's not right, is it?

One of the things
that's been really challenging

is being not believed,

and so I've made notes,
conversations.

What I'm hoping is that

it becomes something for the police,
and for the courts,

because the regulators
have not wanted it.

Oh, here we go.

"Have you informed the police
that there has been a death

"of a completely normal baby
to completely healthy parents?"

"Respectfully, Harriet was not
a completely normal baby.

"At postmortem, there was evidence
of ascending infection,

"a recognised cause of stillbirth.

"We do not consider that
there has been any criminal act

"or omission to prompt us to report
Harriet's death to the police."

There was no infection, was there?

And you were a physio?

Yeah, which I loved.

Loved my job. Worked really hard.

'So, both Sarah and I
lost our jobs.'

Now, they will say
it's for other reasons,

but we're clear, it's cos
we were blowing the whistle.

'I'd got a letter from my employer

'asking about my non-attendance,

'and the HR lady said that
she would continue to pay me

'until two weeks
after Harriet's funeral.

'And then I'd stop being paid.

'Obviously,
our legal team challenged that.'

'I was off sick,
and then, out of the blue,

'got an email
from the medical director, saying,

' "Dear Jack,
can you please make an appointment

' "so that we can discuss
your obligations to the Trust?"

'We had that meeting,

'and we spent most of the meeting
whistle-blowing,

'and at the end of it, he said,

' "I'm sorry, but you're not gonna
have a job for much longer,

' "so let's agree
that your last day is..."

'Well, it was December 2018.'

'You know, I always say it,
but to put it frank,

'you know, they killed our daughter,

'they've ruined our careers,
and they've ruined our lives.'

SHARMA: It's OK.
You all right? Yeah.

Nice to see you.
And you.

Hello! You've grown.
He's just woke up.

He looks like me
when I've just woken up.

How are you?

OK. Yeah. This is...

..erm... hard.

Hey, Ama.
Hello, mate. Sorry.

That's all right.
It's been a while.

It's been very hectic for us
recently. Yeah, I know.

So, you're moving?
Yeah, yeah.

We just don't feel safe here,
to be honest. Yeah.

I feel like a voyeur in your life,
you tell me so much.

If it wasn't for you, then
there'd be no-one listening to us.

I remember standing in that kitchen,
when I was first speaking to you.

The first time
that someone had believed us.

Yeah.
You understand?

You don't realise
what you've done for us.

You really don't.
Thank you.

You're doing good stuff, too,
by the way. This...

This is fighting that you're doing,

and everybody
that shoulders this burden

moves it on a little bit.

What's your background again?

Because you say
you know about ventilators.

So... So, I, erm,
was working with children

with complex health conditions.
OK.

Erm, so needing oxygen...

Night-time CPAP
and that sort of stuff. Yeah.

There are some people
who I think already want

to share their experiences.

Ama and Sharma,
are you comfortable to...

Yeah?

My name is Sharma Thomas, erm...

and I'm here to share mine
and my partner, Ama Maduako, erm...

our experience
at Nottingham City Hospital.

Erm, so...

From the moment
our twins entered this world,

we raised our voices in concern

to the nurses
and to the senior management.

They labelled us as parents who
didn't want our kids to have oxygen

and forcing us through a five-month
child protection investigation.

This left us unable to mourn
for the loss of our daughter.

She was four months old

and spent her entire life
confined to a hospital bed.

Ama, we've got some vital stuff
that needs to happen.

Erm, Donna needs us to collate
our evidence and get it to her.

Can you do that
before you move away? Yeah.

Every email, meeting memo,
phone call memo, everything. Yeah.

You know, we were concerned
about the ventilator,

because, erm, our concerns were that
they were misusing the pressures.

I raised a question
about the ventilator.

The machine wasn't working.
And they were trying to fix it.

They were stood there...
Yeah.

How is this not in front
of the coroner?

They haven't told the coroner
that this happened.

Yeah. They haven't told the coroner.
What they did after this event

was they went and reported us
to social services

and said
we're refusing medical treatment.

We were actually in the hospital

going through
the discharge, erm, planning.

Yeah. And then she dies.
She died on 25th January.

So they delayed her release
because the social services

was trying to basically
get a court order against us.

We just wanted clarity
on what treatment

the hospital were giving Adaora,

but the hospital interpreted that
as us refusing treatment.

ZEEK CRIES
Aw...

Bless you.

Right, thank you
for looking after me.

Just, just about.

I shall leave you to it.

Ta-ra.

ZEEK CRIES
Come here. 'Ey.

Er, come on.

PRINTER WHIRS

The stuff I'm printing now
is evidence,

you get what I'm saying?

Have you got the medical note
where they review Adaora's machine?

Erm...

Do you need me to send it you?
Yeah, could you send me that?

That's pretty key evidence.

You know when they first put her
on the ventilator?

When it went wrong? Yeah.

When it went wrong...
And they didn't tell the coroner.

But on her documents, they've said
that they don't know what caused it.

And then you have the nerve
to tell the coroner

that I caused harm to my daughter,
knowing that we're bereaved parents.

Maybe we should try
and call the coroner's office again.

They're not gonna talk to us.
It might be worth a try.

RINGING TONE

That's if they even pick up.

Hi. Hi, erm...

I was wondering if I could speak
to a representative?

My name's Ama Maduako.

Adaora Maduako.

Yeah, it was 5th of September 2022.

OK.

HOLD MUSIC PLAYS

When it comes to NUH,
like, not everything's about race,

but some things are about race.
Yeah.

Like, think about it,
Jack, he's done so well,

done so much for us,
so much for all the families,

but they're listening to him.

Yeah.
Why? Because he's a doctor.

He's reputable.

Who am I gonna listen to?

20-year-experience doctor
or Black guy from London?

If it wasn't for someone like him
being the spokesperson...

then why should they listen to us?
Yeah.

It sounds harsh, but that is
literally what it boils down to.

HOLD MUSIC PLAYS

HOLD MUSIC STOPS,
DISCONNECT TONE

Yeah, that's what they do.
They do that all the time. Yeah.

That's literally
the fifth time they've done that.

Usually, they'll just respond
and be like,

"Oh, yeah,
we're not talking to you."

But they just started hanging up.
That's what they do. Yeah.

He's conked out.

Let me get him a blanket.

Go on, have baby Adaora's blanket.

You all right?
Yeah.

It's just seeing her blanket.
Yeah.

Cos, like, he looks like her when...

when he sleeps.

So...

SARAH: You've been told
you're just one of those things.

"Babies die sometimes." They don't.

Because it isn't
one of those things.

Babies shouldn't just die.

NATALIE:
I will always talk about my son,

and I will always tell his story...

SHE SNIFFS

..because I was blamed for his death
for that long

that I actually started
to believe I'd done it.

And I started to believe

that I didn't deserve
my other five children.

FELICITY: I thought,

"They've covered up
and lied on all of my situation."

Eight years on,
I'm meeting families today

that have been told, as I was,
that it was my body's fault.

That was a lie.

AMA: They are trying their hardest
to gaslight and to misrepresent.

But there's nothing
they can do or say

that can change
what I know to be reality

because I was there,
and we witnessed it.

Right, where shall I do this one?

What background? Out there?

Something different?
It's good, I think.

I can't stop humming Peppa Pig.

SARAH LAUGHS
Hello.

JACK CHUCKLES
Oh, yay!

Well done. Hello.

'Having our Facebook group
of bereaved and harmed families

'means we can quickly
update everybody

'with information that might help
with their cases against NUH.'

There. Happy?

Erm...

One of the main things...
Well, you can talk about Harriet

and say we didn't get a look
for a prosecution

cos of this three-year limit
that we weren't aware of.

So just to make sure
everyone is aware of this

and how to contact them.

Hello, this is a video
about the Care Quality Commission

and what they should be doing, erm,

and how to access them and why.

What they do is they inspect,

give out ratings,

and they also prosecute.

So they are responsible
for prosecuting the hospital

and the hospital staff.

But there's a key piece about this.

The law is that
they have three years to prosecute.

If you are within that three years,

act, and do it loudly and clearly.

This rule is appalling.

Three years is nowhere near
long enough,

and to not let people know is awful.
Yeah.

Yeah.

I mean, it's survival for the first
couple of years, isn't it? Yeah.

And survival even if the hospital
have done a great job

and are communicating with you.
Yeah.

Not survival
and then you've got to fight a...

..massive system.
Mm.

I believe
they're a failed organisation.

How can you have
so many baby deaths,

and you are responsible
for prosecuting them...

..and yet,
there are only two prosecutions

against maternity units in the UK?

'It's fair to say we all believe

'the CQC must have
deliberately run down the clock

'in order to avoid prosecutions,

'because there have been so few.'

I don't think he understood
just how much we had

and how much we knew.
WOMAN: No.

Do you know what I mean?
He came across as very much like,

"This is just a bunch of families
that think they know it all,"

until we started talking
and then he was like,

"Wow, I really need to,
like, just sit back a minute

"cos they know
what they're talking about."

And that's the thing,
they underestimate us as families.

We've blown the whistle in there
with the Chief Executive of CQC.

Did you notice, though,
as a regulator on the whole of CQC,

for every one of us in that room
that he had failed

to deliver on a prosecution,

we didn't get an apology?

He didn't, no.

I guess, from my point of view,
hearing that...

..the things that happened to us
that are criminal,

the failure to be candid with us,

and Harriet's avoidable death,

stand no chance of having
a prosecution brought by the CQC

means that I wonder if we need
to bring a prosecution, then,

against the CQC.

Because it was their failures
to act, not ours.

We told them,
numerous people told them,

and they just did nothing, so...

They've failed to act.
..and then that's not our fault.

The real key thing here is actually,
people will deliberately

run down this three-year clock
to deny you...

Access.
..access to that justice.

ALL: Yeah.

I'm just really sorry, you know.

For Wynter's case,
we got a prosecution.

But just hearing your stories,
where your...

The clock's deliberately run down.

NEWS REPORTER: 'Wynter Andrews
died in her mother's arms.

'She lived for just 23 minutes.

'Nottingham University Hospitals
NHS Trust

'has received a fine of £800,000.

'This is the first time

'that Nottingham University
Hospitals NHS Trust

'has ever been
criminally prosecuted.'

I am the mum to Wynter Andrews,

who died in 2019
at Queen's Medical Centre.

After Wynter died,

we were in the bereavement suite
when the coroner rang us.

And the coroner said,

"I've been looking at your notes
from when you came in on Sunday."

And I said,
"I didn't come in on Sunday,

I came in on Saturday."

At which point,
the coroner realised

that the Trust hadn't sent
all the correct records over.

We later, at inquest, discovered
that they'd actually ticked the box

to say that Wynter's death
was an expected death.

Wynter was a perfectly healthy baby.

There was no reason for her to die.

The coroner ruled that she died
due to the neglect of the Trust.

The Trust failed
to care for us properly.

Had the coroner not rang me
in the bereavement suite,

and had I not said
"We came in on Saturday,"

the coroner would have signed
Wynter's death certificate.

They would have handed it out,

and Wynter's death
would have gone uninvestigated.

NEWS REPORTER: 'This is only one
of two prosecutions

'that the "Quality Care Commission"
has brought

'against a maternity unit.'

NEWS REPORTER: 'The common word used
by the judge about this hospital

'was "failure",
over and over again.'

DAVID JOHNSTON: 'The baby daughter
of my constituents,

'Gary and Sarah Andrews,

'died just 23 minutes
after she was born.'

When they asked questions
about that,

the parents were told
that these things happen

and that if they had to listen
to the concerns of every mother,

they would be overrun.

Thanks to dogged campaigning
by Gary and Sarah,

and other parents
whose babies had died avoidably,

Nottingham University
Hospitals Trust was found

to have systemic failures

and last week
was given the highest...

JACK: 'There's so many red flags
around the safety of this service.'

Three-and-a-half people with
very serious outcomes every week

in a department that says,
"Nothing to see here."

AVI: So...

You're told Harriet's dead...

..then she was taken away?

Er, well, no,
she would be in the cold cot.

They asked if we wanted her
to sleep in the room,

but I couldn't...
Like, during the night.

Erm, but I couldn't handle that.

So, sorry to be blunt,

but she'd be in the freezer bit
there,

and then when we wanted to see her,
then she'd come out.

They asked
if we wanted a postmortem.

They were quite non-fussed about it.

If we don't want her to have
a postmortem, we don't have to,

but we did
because we needed an answer.

We didn't want them to blame her.

I don't know how long it was.

It must've been,
like, ten days or something

whilst her postmortem
was being arranged,

so we still had access to her...

which felt so normal.

And her skin was soft, and...

..she had a crooked toe, which had
been causing you difficulties

through the late stages
of pregnancy, hadn't it?

Cos it was stuck under your...

Oh, yeah, right under my rib.
..under your rib.

She had one slightly crooked toe,
which we assumed was that.

When she went for her postmortem,
that was the last time we saw her.

Yeah.
Erm...

You read her a book and stuff,
didn't you?

I did.
JACK SNIFFS

I remember holding her, just...

..wishing...

that she would come back to life,
couldn't understand it.

And, yeah, we read her that book,
I Love You To The Moon And Back.

And then we said goodbye to her.

And we put her down
and left that room and walked out.

JACK: I remember
the pain was extraordinary.

The pain of her not being alive,

and the pain of
"you killed my daughter."

"You've covered it up,
and you accused her and us."

And, yeah,
I didn't want to be around.

So, yeah, pretty dark days.

But there's still a bit of me
that just thinks,

"I'm a doctor.

"Why on earth did I allow this
to happen to my family?

"I failed to protect my family."

The reality is
that I was 100% in their care.

The parents of a baby girl

who died after mistakes
by maternity staff in Nottingham

say they'd give back the settlement
awarded for negligence

to have her back.

NEWS REPORTER: 'Jack and Sarah
have been awarded £2.8 million,

'thought to be the largest pay-out

'for a stillbirth
clinical negligence case.'

AVI:
When did you put in a claim?

Erm, we met that barrister
around August, September of 2016.

Yeah, he told us we didn't have
any psychiatric issues,

we'd get a standard ten grand
for a stillbirth,

and we wouldn't get any change
at the hospital.

But that's another thing,
like, we wouldn't have done that.

It was literally to get answers.

And then, you know,
you do go down this route of,

"Well, the only way they respond
is financially."

That's what hurts them.

They don't give a shit
about anything else.

LOTTIE: Come on...

Can you cover both of my feet?

SARAH: Yeah, hold on.

LOTTIE GIGGLES
AND SQUEALS

Say, "Toe monsters!"
I can see your toes!

Argh, toe monsters!

'I stress about Lottie.

'Erm, I feel...

'it's much more difficult
to talk about Harriet now cos I...

'feel that Lottie's innocence

'has just been completely stolen
from her.'

Oh!

Can you do it again?
Yep.

Whoa!

'So it's not just me and Jack.
It's her.

'You know, a childhood of growing up

'with a dead sister
who should be alive.'

Just put it on me gently.

'I worry I get that balance wrong.
We do talk about Harriet.'

Oh, look at that.
That's like a pink finger monster.

LOTTIE GIGGLES

LOTTIE SQUEALS

'I think, now I've had Lottie,

'I grieve the missed milestones
with Harriet, too.

'You know,
I've seen Lottie's first steps.

'I'll never see Harriet's.

'You know,
I'll see Lottie go to school.

'I haven't seen Harriet
go to school or anything like that,

'and it just adds an extra layer
onto your...

'onto your grief.'

I do this.

'It's just so painful sometimes
to let my mind even wander there.'

LOTTIE GIGGLES

Let's wipe your hands, please,
and your feet.

Stand up here.
OK.

AVI: One of the things
I was thinking about

was the impact of it, then,
on the two of you...

..in your relationship.

Erm...

Yeah, it's been really difficult.

Right.

'Are these made with your home-grown
tomatoes, Lottie?' 'Yeah.'

LOTTIE SLURPS
Good eating.

JACK LAUGHS
Proper Italian.

'I feel like after Harriet died,

'I made sure that, you know,

'Jack was involved
and everything like that,

'cos it's so easy
for fathers not to be involved.'

Mmm.

'And then I feel like
it got to a point where

'I wasn't recognised...

'what I'd been through...

'..and I just felt really alone.'

Keep it up, if you want.

'Jack's response would perhaps
be more impulsive than mine,

'so he'd want to email people
straight back,

'whereas I reflect a bit on it.

'Then that just made me
really anxious.'

Hello. Oh, hold on, let me
just clean this paint up first.

I do, yeah.

'I felt like every day,
there was some confrontation

'with the hospital
or with someone else.'

Oh, my goodness. Look at that!

Wow.
This is turning into a spot fest.

I kind of thought it was just
with one senior midwife

to put our views across,
but it will be...

'I find it easier to...

'deal with conflict
and confrontation.

'And I found it quite difficult
to not be able do it.

'That left me very stressed.

'You know,
we need to be solving this now.'

That's not a meeting
that I want to be in at all,

and I don't think it's appropriate
for us to be in with them, and...

Just two very different ways
of doing it. Yeah.

AVI: You've been involved in
something very intense, ongoing.

You've put a lot of effort into it,

but the impact is that
you don't live together any more?

Mm.
Yeah.

And haven't for nearly four years.
Hm.

LOTTIE SINGS

'Lottie was born. We separated.'

I can't remember, Lottie.

LOTTIE: This little piggy
went to market.

NEWS REPORTER: 'Today marks one year
since the review

'led by senior midwife
Donna Ockenden began.

'It's the largest maternity review
of its kind,

'with 1,800 families involved.'

NEWS REPORTER: 'The staff
and managers and former managers

'aren't compelled
to come forward to your inquiry,

'your review, are they?'

DONNA OCKENDEN:
'The very clear message from me

'is that I am expecting
all current and former staff

'who receive a formal letter from me
to co-operate.

'In the unlikely event that anyone
decides not to co-operate with me,

'I will take this
to the top of the NHS

'and, if necessary, to government.'

I think, if it wasn't
for our connections,

nobody would have told us some of
the stuff that they've told us.

But then those people
won't speak up.

Without whistle-blowers,
it becomes a more difficult review.

NEWS REPORTER:
'Nottinghamshire Police has said

'it will launch
a criminal investigation

'into failures in maternity care
at the city's hospitals.

'Holly,
how is this police investigation

'likely to affect
Donna Ockenden's ongoing review

'into maternity services
at Nottingham's hospitals?'

'Speaking earlier today,
Chief Constable Kate Meynell says

'she wants to work
alongside the review

'whilst not hindering its progress.'

NEWS REPORTER:
'Donna Ockenden expects her review

'to take at least 18 months.

'For those who've lost loved ones,
though,

'it's a step closer
to getting the answers they need.'

So, as of yesterday,
we had 1,813 families

who are actively involved
in the review.

In the next couple of weeks,
I'm expecting, as chair,

to receive contact details
for another 70 families

that the Trust have assessed
are part of the terms of reference.

We've got 720 staff
who are now in contact with us.

The government fully endorsed
my work in March 2022.

We're two years down the line.

There is still an awful lot
for government to do

right here and now

to improve maternity services
for all mothers in England.

A lot of families met in person,

some for the first time
a few weeks ago,

to share their experiences.

What do you think is the benefit
in families doing that?

'What families said to me was that
there is something very powerful,

'and some families said healing...

'that they've, you know, realised,
many of them for the first time,

'that they weren't on their own,
it wasn't just them.

'Families told me
how the harm to their babies

'and their children had broken them.

'Marriages and relationships
simply haven't survived the stress

'and distress
caused by maternity harm.'

Back in November,
I did a number of home visits

and met families face to face
here in Nottingham.

'Hearing of discrimination,
of racism,

'of some staff being dismissive
and unkind.

'We will not tolerate
this behaviour.'

AMA: This is just family stuff.
SHARMA: Yeah.

'It just doesn't feel like
it can be a home for us any more.

'I just don't feel safe
living in a city

'where they have
a hospital system like this,

'they have a social services system
like this,

'and you can be falsely accused.'

SHE SNIFFS

These are her, erm...
You haven't seen these, have you?

No.
These were her 3D... casts.

SHE EXHALES

SHE SNIFFS,
SHE EXHALES

Can you get a cloth
so I can clean it?

You can tell we don't go
in her stuff, hey? No.

SHE SNIFFS

NEWS REPORTER:
'Well, earlier today,

'the Chief Executive of
Nottingham University Hospitals says

'that he will fully co-operate
with the police investigation.

'He's already working closely with
the independent review, he says,

'to ensure full transparency there.'

DONNA OCKENDEN: 'So, it is
the 28th of February 2024.

'We are in Nottingham
for a family meeting

'with the chair and chief exec

'of Nottingham University Hospitals
NHS Trust.

'I've got Nick and Anthony here,

'so can I just say
"Over to the families?" '

JACK: So, thank you so much

for doing
something that is remarkable

and remarkable in the setting of...

erm, not having
anything like this before.

When I took up post 18 months ago,

it seemed to me that we needed
to step up our engagement

with the review and particularly
put some resource in place.

Now that the numbers are trebled,

that's become
increasingly important.

So it's probably somewhere
between £1.5 and £2 million worth

of resource every year
because it's a very big review.

What them staff members
need to understand

is they're talking
to somebody whose baby died.

So we're gonna shout,
we're gonna scream.

And then it's...
We're the bad people.

And I'm not. I just want answers.

And when you've got people
shutting the door at every avenue,

you just get angrier
and angrier and angrier,

but then you're the issue.

I think in some senses for us,
as an organisation,

it's important also we're clear
where we failed

and what we're apologising for
if we're going to rebuild.

We've had an official apology
from your predecessor,

and I can assure you,
it changes absolutely nothing.

What I want, as a mum, is to know
that those midwives

who have done it
to all of these mums

are retrained
or held to account or...

If I may, can I just say
what we've said about...? Hm.

WOMAN: Yes, yes.
So...

HE SIGHS

I said, "Let me be very clear
that as the public record shows,

"in the area of maternity services,
where we've failed

"the families and communities
that we exist to serve.

"To make matters worse,
having failed them,

"we have too often worsened things

"by not responding
to them appropriately.

"Some families
who we have had the chance to meet

"have told us
they want a meaningful apology

"that they recognise
as meeting their needs,

"including accountability
and a change in the culture."

Now, you may still feel
it's not the right time,

but I think it's important
that is discussed

and probably discussed
outside of here.

SARAH: Just three points
I'd like to add in.

I just want to get it
in the final apology.

I want you to apologise
for victim blaming,

I want you to apologise
for gaslighting,

and I want you to apologise
for the cover-up.

That's what I'd like
in the apology,

cos that's all evidenced.

ANTHONY: At a senior level,

we have recruited
pretty much a whole new team.

All the people we've appointed
at executive level

since we've been in post
have been external to the Trust.

JACK: I think it's incredible
that you have changed a board

who have sat, some of them,
for a very long time.

It shows that you've listened to us.
WOMAN: Yeah.

That... That's impressive.

Wow.

'The struggle to get
an independent, proper review

'in Nottingham was awful.

'Now we have the review...

'and the police are investigating.'

I want to see people in court
for the death of my daughter

and so many other babies
and mothers.

This is just the beginning.

We are not done,
we are not finished,

and we will not stop
until that happens.

HE PLAYS
'MOONLIGHT SONATA'

SARAH: 'We still spend
a lot of time together.

'I think we have
some really good times together.'

I think we have some
really bad times together, erm....

'It just exposed...

'..how different we are,

'which is, I suspect, how everybody
might be if their child died.

'You think you're similar...

'..but wait till you have to deal
with this, and then...

'leaving the cap
off the toothpaste tube

'becomes divorce material.

'Because it's an awful lot
to put people through.

'And, you know,
I hold individuals responsible...

'..for my daughter's death...

'..for my mental health...

'..my marriage.

'In order to start healing...

'..we need justice.'

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