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NEWS REPORTER: 'An inquiry into the deaths

'of babies in Nottingham is expected to become

Official YIFY movies site: YTS.MX

'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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