The parents of a baby girl who died 23 minutes after being born under the care of an NHS trust have slammed the organisation for “empty promises” after watching it be prosecuted for the second time.

Wynter Andrews died in September 2019 under the care of Nottingham University Hospitals (NUH) NHS Trust, leading to the organisation being fined £800,000 in 2023.

On Wednesday, the trust was handed a record £1.6m fine – the largest ever for an NHS trust for maternity care – following another prosecution brought by the Care Quality Commission (CQC) over the deaths of babies Adele O’Sullivan, Kahlani Rawson and Quinn Parker in 2021.

After the sentencing, Wynter’s parents Sarah and Gary said the case confirmed what they had said “all along – Wynter’s death was not an isolated incident”.

The trust remains at the centre of the largest maternity inquiry in the history of the NHS. The review began in 2022 and is looking into more than 2,000 cases dating back to 2012.

Mr and Mrs Andrews watched Wednesday’s proceedings at Nottingham Magistrates’ Court from the public gallery, as the families of Adele, Kahlani and Quinn heard the sentence being passed by District Judge Grace Leong.

In her remarks, the judge said: “There were similarities between the current cases and the failures concerning Baby Wynter namely, a lack of escalation of care, the inadequate communication systems and the failure to provide clear and complete information sharing.”

These failings, the judge said, were among a “catalogue” of others that led to the babies and their mothers being exposed to significant risk of avoidable harm, and in Quinn’s case, resulted in him suffering avoidable harm.

After Wynter’s death in 2019, a CQC inspection of NUH in October 2020 led to the trust being placed in “special measures”.

It was inspected again in April 2021 and a number of improvements had been identified, the court heard.

That inspection took place “either around the or after the death of baby Adele“, and the report was published in May.

Baby Kahlani died in June, followed by the death of baby Quinn in July.

Separate inquests into their deaths highlighted a “series of errors” and “missed opportunities” in their care.

The judge added there was “no explanation on why, notwithstanding the number of guidelines to aid and assist the medical staff, the grave mistakes in the care and treatment of the mothers and their babies recurred”.

During the inquest into baby Wynter’s death in 2020, the coroner said she had received an anonymous later from midwives at NUH’s maternity unit, addressed to trust bosses, warning of a “potential disaster” as a result of staffing issues.

That letter was dated 10 months before Wynter’s death.

Mr Andrews said the trust had “failed to listen” to those whistleblowers, adding they had been promised the trust would do “everything in its power to ensure such a tragedy would never happen again”.

He added: “We watched the proceedings of [Wednesday’s] prosecutions from the public gallery as concerned parents – who were promised several years ago that our daughter’s death would bring about change.

“It is apparent 1739415478 that those entrusted to bring about change failed to do so.”

While the maternity review – being led by senior midwife Donna Ockenden – is ongoing and now expected to reveal its findings in June 2026, the couple urged the Department of Health and Social Care to commission an independent, external investigation involving healthcare regulators.

They said: “The time for empty promises is over. The time to listen and learn is now.”

Lawyers speaking on behalf of the families of Adele, Kahlani and Quinn also called for greater accountability and action.

Natalie Cosgrove, on behalf of Quinn’s parents Emmie Studencki and Ryan Parker, said: “The medical expert confirmed that had the trust taken just one of many opportunities to provide suitable care, then Quinn would be sitting down for his afternoon snack at nursery right now.

“Instead, he is buried in the ground.”

Sadie Simpson, speaking on behalf of the parents of Adele and Kahlani, added: “Whilst it is accepted that some changes have been made, for years, families and staff have raised alarm bells about the quality of care at NUH, and tragically, the consequences have been devastating.

“This case reinforces the urgent need for meaningful and lasting improvements, and the time to act is now.”

Following the hearing, NUH chief executive Anthony May said: “The mothers and families of these babies have had to endure things that no family should after the care provided by our hospitals failed them, and for that I am truly sorry.

“Today’s judgement is against the trust, and I also apologise to staff who we let down when it came to providing the right environment and processes to enable them to do their jobs safely.”

The trust added it had made a number of changes through its Maternity Improvement Programme, including increasing staff numbers and launching a new foetal medicine unit and neonatal unit.

“There is more to do, but we know we are on the right path to improvement,” Mr May added.

An NHS trust has been fined £1.6m for “avoidable failings” connected to the deaths of three babies in 2021.

Adele O’Sullivan, Kahlani Rawson and Quinn Parker died shortly after they were born – all within 14 weeks of each other – while under the care of Nottingham University Hospitals (NUH) NHS Trust.

The trust admitted six counts of failing to provide safe care and treatment to the babies and their mothers on Monday, following a prosecution brought by the healthcare watchdog, the Care Quality Commission (CQC).

On Wednesday, family members cried in the courtroom as district judge Grace Leong expressed her “deepest sympathy” to each of them, and said the trust they put in NUH to deliver their babies safely had been broken.

Adele died at just 26 minutes old on 7 April 2021, Kahlani died aged four days old on 15 June, and Quinn was two days old when he died on 16 July.

In a statement read out on behalf of Quinn’s parents outside Nottingham Magistrates’ Court, lawyer Natalie Cosgrove said the prosecution would not bring him back “but although he never spoke, he has a voice, and it has been firmly heard”.

“Quinn died from a long list of failings and Emmie’s life was put at risk,” she said.

“Some failings so basic, that a passing stranger on the street would have provided better attention to, and quality of care.”

Sadie Simpson, on behalf of the families of Adele and Kahlani, added the prosecution “must act as a turning point”, adding it was “yet another acknowledgement of serious failures”.

The fine is the largest ever for an NHS trust for maternity care, the CQC said, and the fifth maternity prosecution it has brought overall.

It was reduced from £5.5m, taking into account the trust’s financial position and guilty pleas, the court heard.

The judge said there were similarities among the “catalogue of failures” across the cases, in which all the mothers suffered a placental abruption, a serious condition in which the placenta starts to come away from the wall of the womb.

She told the hearing, which was attended by NUH chief executive Anthony May, that the “catalogue of failures” in the trust’s maternity unit were “avoidable and should never have happened”.

Of the babies’ families, the judge added: “They placed their trust in a system meant to protect expectant mothers and keep babies safe – and that trust was broken.

“Three and a half years have gone by, yet for the families no doubt their grief remains as raw as ever and a constant presence in their lives that is woven into every moment.

“It is very difficult, if not impossible, to move on from the failures of the trust and its maternity unit.

“The weight of what should have been done different will linger indefinitely.”

Adele was born prematurely following an emergency Caesarean after her mother, Daniela O’Sullivan, noticed bleeding and suffered abdominal pains.

However, no vaginal examination was carried out and the court previously heard there was a delay in identifying that she was in labour.

An inquest into Adele’s death found a series of “missed opportunities” in her mother’s treatment, but could not say whether or not they led to the baby’s death.

In Kahlani’s case, his mother Ellise Rawson had complained of a lack of foetal movement days before she had to undergo an emergency Caesarean.

The trust said in an interview under caution that it accepted the monitoring in her case was poor “from the outset” and that key information about her condition had not been passed on to consultants.

A coroner said “failings in care” led to a 20-minute delay in carrying out an emergency Caesarean section.

The court heard Emmie Studencki went to hospital four times before her son Quinn was born in July 2021 after suffering bleeding.

On the final occasion, she called an ambulance after having a major antepartum haemorrhage.

Prosecuting on behalf of the CQC, Ryan Donaghue told the court it was recorded by a paramedic that she lost about 1,200ml of blood but “those records did not find their way to the hospital notes”.

Quinn was “pale and floppy” when he was delivered by emergency Caesarean section, the court heard.

An inquest found a series of errors contributed to his death.

The trust is currently subject of the the largest maternity review of its kind in NHS history, with about 2,500 cases being looked at.

It is the first trust to be prosecuted by the CQC more than once, after it was fined £800,000 in 2023 for failures in the care of Wynter Andrews, who died 23 minutes after being born at the Queen’s Medical Centre in Nottingham in September 2019.

The court heard the trust has an average turnover of £612m, and the judge said she was “acutely aware” that all its funds as a publicly-funded body were accounted for and that the trust was currently operating at a deficit of about £100m.

She said: “I can’t ignore the negative impact this will have… but the significant financial penalty has to be fixed to mark the gravity of these offences and hold the trust to account for their failings.”

At sentencing on Wednesday, the trust was also told to cover prosecution costs of £67,755.23 and ordered to pay a surcharge of £190.

Following the hearing, NUH chief executive Anthony May said: “The mothers and families of these babies have had to endure things that no family should after the care provided by our hospitals failed them, and for that I am truly sorry.

“Today’s judgement is against the trust, and I also apologise to staff who we let down when it came to providing the right environment and processes to enable them to do their jobs safely.”

He said the trust believed it now had a “safer and more effective maternity service”, and hearing the families in court gave the trust more “incentive” to improve.