NHS Edited Dead Baby's Medical Records After She Died, Report Found

An independent review into maternity care at Nottingham University Hospitals NHS Trust has highlighted an earlier NHS inquiry, which found hospital staff altered the medical records of six-hour-old Kate Stanton-Davies after she died.

The review, led by senior midwife Donna Ockenden, examined the care of around 2,500 families between 2012 and 2025. It concluded that hundreds of mothers and babies suffered avoidable harm and identified repeated failures in patient safety, leadership and the review of serious incidents.

Although Ockenden's review did not find evidence that records had been altered in Nottingham, it referred to the earlier Shrewsbury and Telford maternity inquiry. That investigation found staff amended Kate Stanton-Davies' clinical observation notes after her death, one of the findings that emerged from the earlier maternity scandal.

Nottingham Review Finds Avoidable Harm

Ockenden's review concluded that at least 156 babies might have survived if appropriate care had been provided, while another 105 suffered serious injuries linked to failures in maternity care. Six mothers also died during the period covered by the investigation.

The review also graded 520 cases involving mothers and babies as raising significant or major concerns about the care provided. It described a 'bullying and toxic culture' involving a minority of senior leaders and found repeated opportunities to improve safety had been missed.

The report also criticised the way complaints and internal reviews were handled, saying many families were left without clear explanations after raising concerns.

Earlier Inquiry Highlighted Record Changes

The report referred to findings from the earlier Shrewsbury and Telford maternity inquiry, which concluded that staff altered Kate Stanton-Davies' medical records after her death. Investigators found the amendments altered the documented timeline of her care, raising questions about how the case had been examined internally.

Ockenden said NHS organisations must be more open when reviewing maternity incidents and ensure families receive accurate accounts of what happened. She also called for lessons from serious incidents to be shared more effectively across maternity services.

Families Continue Seeking Answers

The review highlighted several families whose experiences illustrated the failures identified during the investigation. Among them were the parents of Harriet Hawkins, who was stillborn in 2016 after delays in receiving appropriate care. Ockenden said the trauma they experienced was worsened by what she described as a 'systemic cover-up and investigations designed to mislead', adding that their efforts to uncover the truth became a 'patient safety catalyst' for the Nottingham review.

The report also examined the case of Wynter Andrews, who died 23 minutes after an emergency Caesarean section in 2019. Her parents said they were told by a clinician that the hospital would be 'overrun' if staff acted on every mother's concerns.

Government Response

Responding in Parliament, Health Minister James Murray described the findings as 'chilling' and apologised to the affected families. He said the government would publish a national maternity improvement plan before the end of the year.

Nottingham University Hospitals NHS Trust apologised to families and said it accepted Ockenden's findings and recommendations.

Separately, the Independent Office for Police Conduct continues to investigate matters linked to the Nottingham trust. The findings will form part of the ongoing scrutiny of maternity care across the NHS.