In the early hours of April 17 2021, Adele O’Sullivan was born without a heartbeat at Nottingham City Hospital.
Described as “pale and floppy” upon delivery, Daniela’s daughter was declared dead just 26 minutes later.
Ten months later, a coroner concluded that, whilst it might not have been possible to save baby Adele, there were “missed opportunities” to improve her survival hopes.
Following the inquest, Mrs O’Sullivan added her voice to growing calls for a public inquiry into the maternity services at City Hospital and Queen’s Medical Centre.
She said she had "completely lost trust in the system".
Sadly, her case is not so much of a rarity.
Nottingham University Hospitals (NUH), the NHS trust which runs the hospitals, is currently subject to a thematic review of its maternity services.
It follows 46 babies suffering brain damage and 19 being stillborn in the city between 2010 and 2020, resulting in millions of pounds paid out in negligence claims.
The trust has since implemented a maternity action plan.
'We struggle on a daily basis'
But beyond the reviews, the statistics and the sums of money lie a series of tragic stories.
Gary and Sarah Andrews lost their baby, Wynter, in 2019 after neglect in her care.
Whilst they welcomed the thematic review, the couple from Mansfield said it would not be enough.
"Although we are happy to support the thematic review, and we've provided our story, we worry that the review is quite limited," Mr Andrews told Nottinghamshire Live.
"We are concerned that there are families that are out there that don't know they were harmed.
"With the recent inquest of Adele, it just brings it all back. It just makes us more determined that the change is enacted and that those difficult questions are asked."
Mrs Andrews added: "We struggle on a daily basis. We've been left with serious mental health problems following this, but we keep on fighting because we want to not be sitting here in two years time looking at a family have to go through what we went through."
In December last year, Sarah and Jack Hawkins were compensated £2.8 million after maternity failings led to the stillbirth of their baby, Harriet, in 2016.
Mr Hawkins said he had "no confidence" in the thematic review.
"We don't hold out any hope," he said.
"We have no confidence in it, they don't, in our minds, want people to come forward.
He said that there "has to be" a public inquiry.
"We have to have access to emails, records, we have to have the opportunity to hear why people didn't do what they said they'd do., why parents were ignored and blamed. The opportunity is to really learn.
"Absolutely we are calling for a public inquiry, and we'll get one."
Mr Hawkins echoed the calls of the chair of Nottinghamshire County Council’s health scrutiny committee, Councillor Sue Saddington, who planned to write to Health Secretary Sajid Javid over concerns with the trust's leadership.
"We are desperate for him to recognise how much we need his help and power."
A spokesperson for NUH said: "We are doing everything in our power to ensure the families using our maternity services get the best possible care.
"We are fully co-operating with the ongoing independent review, commissioned by NHS England and NHS Improvement and the Nottingham and Nottinghamshire Clinical Commissioning Group."
Since the cases of Wynter, Harriet and Adele, and a rating of 'inadequate' by watchdog CQC, NUH has introduced a number of changes in maternity care.
In October last year, it recruited 36 new midwives for its hospitals.
The trust also worked to improve its handovers - rewriting its guidance, hiring six consultants and changing work patterns, which has decreased the number of handovers from three to two.
Technological changes, including more monitoring equipment for midwives and improved information systems, have been implemented.
Improvements have also been made in the way lessons are learned from incidents, NUH says.
'There is no magic bullet'
Dave Ratchford, regional officer for Unison, said the union felt NUH had "stepped up" with the maternity plan, however said the service was likely to continue struggling as a result of NHS underfunding.
"What we see as the real challenge here now is recruiting sufficient midwives," he said.
"That's a real issue and that stems back to whether the government are underfunding the NHS, which we say they are.
"We believe, as far as we can see, the trust is stepping up in trying to put things right that have clearly gone wrong, but if we are going to underpay NHS staff and ask them to pay thousands to train then we're going to have a problem.
"We have confidence in the resilience of staff to bounce back. We believe that the services can be turned around, but there's no magic bullet to put all this right."
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