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00:00:00Untertitelung des ZDF für funk, 2017
00:00:30Untertitelung des ZDF für funk, 2017
00:01:00Untertitelung des ZDF für funk, 2017
00:01:02I don't really know what to say
00:01:02because my daughter didn't survive routine health care
00:01:08I'm Sarah Hawkins
00:01:09I'm a mummy to two beautiful daughters
00:01:12Harriet should be seven
00:01:14and Lottie is four
00:01:16Hi everybody
00:01:18I'm Natalie
00:01:19My son Cooper
00:01:20Never opened his eyes
00:01:22He never moved a muscle
00:01:23He never fed
00:01:25Winter was a perfectly healthy baby
00:01:28There was no reason for her to die
00:01:31I'm a harmed mum
00:01:32And the problem is, it doesn't stop
00:01:35Because we're still here
00:01:37Eight years on
00:01:38What we're most worried about
00:01:40Is that harm is ongoing
00:01:42Donna Ockenden is calling for more families
00:01:45To come forward
00:01:46Or her inquiry risks being a failure
00:01:48This is a call to arms
00:01:51We must now all speak to Donna
00:01:54To get up the justice we deserve
00:01:56Thank you
00:02:24So I met Jack in 2008
00:02:26We both worked at the hospital at the time
00:02:28We both worked at the hospital at the time
00:02:30So I met Jack in 2008
00:02:32We both worked at the hospital at the time
00:02:44I was a physio and Jack was one of the doctors
00:02:58And he told me a really bad joke
00:03:03I had a bad shoulder
00:03:05And I was trying to get you to fix it
00:03:08You were like so dismissive
00:03:09Shoulders were my speciality
00:03:13Yeah, but still
00:03:13Read the signs
00:03:15Yeah
00:03:18I got married November 2013
00:03:23I think it was less than a year
00:03:25After I got engaged
00:03:26So this wasn't often spoken about
00:03:29Yeah
00:03:30We were both one of four
00:03:35Then we thought we'd have four kids
00:03:37Country house, dog
00:03:38I thought we said three
00:03:39Oh no, because you can't have an odd number
00:03:41Fair enough
00:03:43Lottie, would you like cordial
00:03:59Or a fruit shoot
00:04:01Yeah, in your Charlotte cup
00:04:04You can do your work
00:04:07We do ours
00:04:08Oh, you can do some work
00:04:10Can you hear it?
00:04:11Mum, I'm just a little louder
00:04:13Is that okay?
00:04:15Yeah
00:04:15Not too loud?
00:04:17Not too loud
00:04:17So this is the timeline
00:04:20Of what happened in our care
00:04:22Yeah
00:04:22I can put that file on the chair
00:04:24And if I have the computer
00:04:26You don't know you're writing it
00:04:27No, I'm right
00:04:28Baby Harriet Hawkins
00:04:31Was born dead
00:04:32At Nottingham City Hospital
00:04:34On the 17th of April
00:04:352016
00:04:36She died as a result
00:04:39Of a mismanaged labour
00:04:40Harriet's father Jack
00:04:42Is a hospital consultant
00:04:44Her mother Sarah
00:04:45Is a senior physiotherapist
00:04:47Both work for the hospital trust
00:04:49Responsible for the death
00:04:50Of their baby
00:04:51Their first child
00:04:52Do you want to just use your normal pen?
00:04:54Yeah
00:04:54Since that day
00:04:56The couple have campaigned
00:04:57To force the trust
00:04:59To acknowledge
00:04:59It made mistakes
00:05:01Mistakes which they believed
00:05:03Had been covered up
00:05:04So let's just be clear
00:05:09What do you think
00:05:10That Donna wants from us?
00:05:13Well I think she needs to know
00:05:15Donna needs to know
00:05:16Basically all of Harriet's story
00:05:19And what went on
00:05:20During my pregnancy and birth
00:05:23Her due date was the 11th
00:05:26Wasn't it?
00:05:27Due 11, 4, 16
00:05:29I started having contractions
00:05:31Through the night
00:05:32So that I never stopped
00:05:34Over the whole 60s
00:05:34Six to nine mins
00:05:36It's been nearly eight years
00:05:40Since Harriet died
00:05:41And I remember every second of it
00:05:44Like it feels like it was yesterday
00:05:45Then that evening
00:05:48That's when we did go in
00:05:50That was the first time
00:05:52That they suggested
00:05:53This was latent labour
00:05:54And that was in our heads then
00:05:56Yeah
00:05:57I made 13 contacts
00:06:00With the hospital
00:06:01They just weren't listening to me
00:06:04When I was asking for help
00:06:05On the 16th
00:06:07They told me to come in
00:06:09And I said
00:06:11Well I need an epidural
00:06:12Because I'm not managing
00:06:12And then she said
00:06:14Oh no you're too early for that
00:06:16But why don't we give you
00:06:18Some diamorphine
00:06:20Which is ridiculous
00:06:21When you think about it
00:06:22A massive dose of opiates
00:06:23And so without the doctor seeing you
00:06:26You had 10mg of diamorphine
00:06:28Codeine
00:06:30We didn't know this at the time
00:06:32Did we?
00:06:33We found this out afterwards
00:06:34Codeine 60
00:06:35And one gram of IV paracetamol
00:06:38Yeah
00:06:39Which is massive isn't it?
00:06:43Huge
00:06:43I've never
00:06:44I just cannot imagine
00:06:46Giving those doses
00:06:48Of those medicines
00:06:48And letting anybody home
00:06:50You know
00:06:52Having these six days
00:06:53Of just begging for help
00:06:55And no one agreeing with me
00:06:57Or
00:06:58You know
00:06:59Basically I felt like a fraud
00:07:00Then on the 17th
00:07:04Phone call to the labour suite
00:07:07And that was the worst phone call ever
00:07:10Yeah
00:07:10She was horrible
00:07:12Yeah
00:07:12That was
00:07:14That lady was just horrific
00:07:17She said
00:07:20I'm sure you're not an established labour
00:07:21So stay at home
00:07:22So I got off that call
00:07:24And I was just lying on the sofa crying
00:07:26And then something started to hang out of me
00:07:30I was 10 to 4
00:07:33We jumped straight in the car
00:07:34To the hospital
00:07:35I walked in
00:07:37There were three staff
00:07:38One of them was
00:07:40The midwife I'd had the phone call with
00:07:42She just shouted down the car door to me
00:07:44Is it still hanging out of you?
00:07:48So then I just burst into tears
00:07:49Because I'd been in labour for like six days
00:07:51And I was exhausted
00:07:52Then that midwife
00:07:56She said
00:07:57Does it feel like you need to push?
00:07:58And I was like
00:07:58Yeah
00:07:59Then she said
00:08:00Oh I can see the baby's head
00:08:01Baby's about to come
00:08:02You're too late for pain relief
00:08:04She had said
00:08:05I'm just going to check the baby's heart rate
00:08:07She struggled to find it
00:08:09So then they called for the doctor
00:08:11And then the doctor scanned
00:08:13And said
00:08:13I'm sorry your baby's dead
00:08:14I think I just wanted to die
00:08:20Yeah, you know
00:08:26Like
00:08:27I was asking for help
00:08:29I think I convinced myself it was a boy
00:08:44I think we had
00:08:45Yeah
00:08:46I quite liked Arthur
00:08:49I remember when we saw her
00:08:55I was like
00:08:55Oh she definitely looks like a little Harriet
00:08:57She does
00:08:58Harriet
00:09:01Ella Rainey-Jotkins
00:09:03She was perfect
00:09:04Wasn't she?
00:09:04Hey, how are you?
00:09:30Hello
00:09:30Good to see you
00:09:31And you
00:09:32Hi Abby
00:09:33Nice to meet you again
00:09:33Well I've had multiple therapists
00:09:35At different times
00:09:37For slightly different reasons
00:09:39Thank you for coming
00:09:40Again
00:09:41We've never seen anyone
00:09:44Together
00:09:45Together
00:09:45I see
00:09:46In therapy
00:09:47We're here because
00:09:49You've suffered the unexpected death of your child
00:09:54And then found yourselves in a years long fight to be heard
00:10:03Yeah
00:10:04Yeah, absolutely
00:10:07The toll that has taken on us needs some sorting out
00:10:11After Harriet died
00:10:17For days, for weeks
00:10:19We expected them to come forward to us and say
00:10:22Right
00:10:23This is the death of a completely normal baby
00:10:26What has happened here?
00:10:28Well they didn't do that
00:10:29Oh
00:10:30It was
00:10:31Nothing's happened
00:10:32Nothing to see here
00:10:33And
00:10:34Hushed
00:10:35And these things happen
00:10:36They
00:10:37Just refused to even have a conversation
00:10:40About
00:10:41What might have happened
00:10:43What else might have happened
00:10:44Do you think it's hungry?
00:10:47Oh
00:10:47Do you want some food
00:10:48Do you think?
00:10:50Ooh
00:10:50Right monkey
00:10:53I'm going to need you to help me sellotape something on the wall
00:10:56You look like a professor
00:10:58They had done their own investigation into Harriet's death
00:11:04We didn't know about their even doing this
00:11:06It was completed
00:11:08It had the wrong place of delivery
00:11:10In the end it said
00:11:11No false
00:11:12By
00:11:13NUH
00:11:14And then they said
00:11:15Earth was infection
00:11:16As in they tried to blame Harriet's death on infection
00:11:19We were saying
00:11:20We don't agree with that at all
00:11:21And they said
00:11:22But this has gone through
00:11:23Six other consultants
00:11:24And four senior midwives
00:11:26Now
00:11:27To us
00:11:29That's
00:11:29A chunk of the department
00:11:31Thinking that this report was good enough
00:11:34And bearing in mind
00:11:35We'd been blowing the whistle
00:11:36All the way through this
00:11:37Saying something's not right
00:11:39Also remember I worked there
00:11:41We hoped that meeting the chief executive and the medical director
00:11:52January 2017
00:11:53They would go crikey yes
00:11:55Okay
00:11:55Something's gone very wrong here
00:11:58But then it became very clear that
00:11:59They were interested in maintaining the position of the hospital
00:12:07I'm just going to put some red here for organisations
00:12:12Yeah
00:12:13And it would have made a big difference I think
00:12:16If they'd said this shouldn't have happened
00:12:18Instead of that
00:12:20We were completely cast out and ignored and vilified
00:12:24We've got these emails from the trust
00:12:34And they have written emails about us
00:12:37Like when can we sue them for defamation
00:12:40They haven't had to fight as hard as they have
00:12:43Their media releases are full of lies
00:12:45I feel like they're trying to make me go crazy
00:12:48Like after all those years
00:12:49You know
00:12:50There's still that thing of
00:12:52Them blaming us
00:12:54Because I do feel like that was one of their tactics
00:12:57Like to make us feel like we were grieving and
00:13:01Crazy
00:13:02And we were broke
00:13:05I was broken
00:13:06And you know
00:13:08We were senior clinicians
00:13:10So what else have they done to other people?
00:13:15We knew we cannot be the only ones
00:13:27We searched the news
00:13:32We found a news report on a young lad who died two years before Harriet
00:13:40Because at cesarean section they cut one inch deep
00:13:44With a scalpel into his head
00:13:47Following the inquest
00:13:54Dr. Stephen Fowley, medical director
00:13:56Said
00:13:57The pathologist concluded that this extremely rare complication of the cesarean
00:14:02Caused Carson's death
00:14:03It will never be known whether had this not occurred
00:14:07Carson would have survived
00:14:08Makes me so angry
00:14:12What on earth
00:14:13After that my life for years was just scrolling social media
00:14:2224-7 just trying to find someone with a dead baby
00:14:26Which takes a toll
00:14:29We set up a Facebook page
00:14:33It started off with a small group of us
00:14:39And then it jumped to 12
00:14:41And then 20
00:14:42And then 50
00:14:43Yeah there's hundreds of us now
00:14:46Talking to each other
00:14:48Sharing information
00:14:50The most horrific community you could want to be part of
00:14:55But at least there are other people saying
00:14:57Yes
00:14:58Your experience is mine
00:15:00I feel a deep sense of responsibility
00:15:11For these other families
00:15:14Who else is coming?
00:15:19Just us I think
00:15:20Is it?
00:15:21The thing is every time we meet there's at least one more bombshell
00:15:24From one of us that we found out
00:15:25I don't think a week's gone by
00:15:27Where there hasn't been something quite shocking
00:15:29That's come to light
00:15:30I mean what we're in 2023 now
00:15:32And we think there's still more to come
00:15:35Yeah
00:15:35When Sarah had to go back and have a bladder scan
00:15:38That they should have done
00:15:39A couple of weeks after Harriet's death
00:15:42When they forgot
00:15:42They then sent us to antenatal clinic
00:15:45With a letter saying
00:15:46Please make sure your bladder is full
00:15:47So we can scan your pregnancy
00:15:48I get that and I don't have a bladder
00:15:51Yeah don't have one then
00:15:53So what do I do?
00:15:54Can't come with a full bladder
00:15:55When I don't have one
00:15:55They still don't even know
00:15:57Even to this day
00:15:57I'm eight years on now
00:15:58Just because it's obviously just Max's birthday
00:16:00They still don't even know
00:16:02Which of my ureters they chopped off as well
00:16:05They chopped off the bladder
00:16:06And one of my ureters
00:16:07And the urologist says one
00:16:09And the two doctors that did it to me
00:16:10Say another
00:16:11I don't even know which body parts I've got
00:16:13When Wenter died
00:16:15And we were in the bereavement suite
00:16:16The government's team had come to us with a letter
00:16:18Didn't they?
00:16:18And I had to point out
00:16:20It's like it's not our son
00:16:21It was our daughter
00:16:22You know
00:16:22And they're like oh we'll go and change that
00:16:24So those little details
00:16:26You know it's
00:16:27I mean if you're going into the room
00:16:29Of a family whose baby's just died
00:16:32You go in there knowing if it's a girl or a boy
00:16:34Don't you?
00:16:35Yeah you would do if there were any consequences
00:16:37Well
00:16:37It's the families that don't remember
00:16:40I got told inquest
00:16:41Was that the coroner?
00:16:43Coroner
00:16:43I'd argue the opposite
00:16:45She favoured the NHS's version of events
00:16:47Because the family had been through something so traumatic
00:16:49That they can't possibly remember in what order those events happens
00:16:53It's exhausting isn't it?
00:17:06Cooper was born
00:17:07He didn't cry
00:17:10He barely cried
00:17:12And I knew then that something was wrong
00:17:14He was born at quarter to two in the morning
00:17:18And he was discharged at half past three in the afternoon
00:17:21Even though I'd raised concerns that he'd never opened his eyes
00:17:25He never moved a muscle
00:17:27He never fed
00:17:29All I got told by midwives was he was my fifth child
00:17:34And I should know how to wake a baby and feed him
00:17:37And to go away and do it
00:17:38He died at quarter past two in the morning
00:17:43While we were asleep
00:17:44We ran 999 and was told to do CPR
00:17:49So I got my son on the floor and did CPR the best I could
00:17:53When the ambulance crew and everybody arrived
00:17:57Me and my husband were arrested
00:17:58I wasn't allowed to sit with my son in the ambulance
00:18:05On the way to the hospital I had to sit up front
00:18:07I wasn't allowed to see him, hold him or touch him
00:18:11It was the hardest thing
00:18:13Was seeing my kids watch their mum being taken away
00:18:17For killing their brother
00:18:18Some of us have fought for years to get our medical records
00:18:36Because we believe some of them are incorrect or incomplete
00:18:40At least we worked at the hospital
00:18:47And that's how we can help others
00:18:50My problem is
00:18:53The memory that I have of Cooper's state of health
00:18:55Is completely different
00:18:57To what the coroner was told at inquest
00:18:59I'm going to make some notes
00:19:03Is it the 17th?
00:19:09Yeah
00:19:09So in here is everything
00:19:13Right up to the present day
00:19:15Wow
00:19:17There is too much here to sort out
00:19:20They think by landing this on my doorstep altogether in one go
00:19:24That I'm just going to look at it and go
00:19:26Nicely redacted
00:19:27Your info, do you know what it says about your son?
00:19:32What was under there?
00:19:33God knows
00:19:33The police officer that was involved
00:19:38Came and brought Cooper's belongings back
00:19:40She said, so has anybody rang you and told you that he had two collapsed lungs on his MRI scan?
00:19:47This is the police telling you?
00:19:49Yeah
00:19:49So I went mad, rang the hospital
00:19:52She said to me, well the reason why I didn't tell you is because you collapsed his lungs doing CPR
00:19:56So you killed your son
00:19:58They made me believe that he had no chance of being brought back to life
00:20:03Because you?
00:20:04Because I collapsed his lungs doing incorrect CPR
00:20:06We were just told that we was being arrested under caution
00:20:15And they had to have an MRI scan
00:20:17And we couldn't see him until they could make sure that we'd not structurally damaged him
00:20:23It'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
00:20:36That it hit me that I hadn't done it
00:20:39Fuck me
00:20:53On Cooper's shelf
00:21:16Yeah
00:21:16This one
00:21:17Yeah
00:21:17You can't really see it very well because it's glass
00:21:20But it has got its picture engraved on it
00:21:22Well let's see
00:21:23Oh Cooper
00:21:27Is that picture in there?
00:21:31Yeah
00:21:32That picture was taken literally minutes after he was born
00:21:34All we've ever done is speak the truth
00:21:39Yet we're always being told it
00:21:40Well we were told at inquest it's not the truth
00:21:42Yeah
00:21:43And that hurts because telling a family who have suffered
00:21:47Such a tragic thing
00:21:50We can't possibly remember what way it happened
00:21:53You will never forget what way it happened
00:21:55No
00:21:56I rang the hospital 17 times and was repeatedly told that there was no beds
00:22:19David had to starve of oxygen
00:22:22And passed away
00:22:24Inside me
00:22:26I was told that she probably wouldn't survive the birth
00:22:31We decided to end the pregnancy
00:22:33Because we didn't want our daughters to suffer
00:22:36I found out the test results came back completely clear
00:22:41You can't imagine that feeling
00:22:44The consultant says well you couldn't have miscarried anyway
00:22:48I'm still going to have to give birth
00:22:52To a baby that's going to come out silent
00:22:55And literally your dreams are shattered in an instant
00:23:00I wonder how my sleep will be tonight
00:23:11Interesting dreams everything
00:23:15Do you have it?
00:23:16Interesting
00:23:17Yes
00:23:18Donna Ockenden the senior midwife recently reported on the maternity scandal in Shropshire
00:23:28Which uncovered more than 350 cases of serious harm
00:23:32Donna Ockenden is leading the independent review examining dozens of baby deaths and injuries
00:23:41And mothers who suffered serious harm at the Queen's Medical Centre in Nottingham City Hospital
00:23:47It's been a very long fight to get this review to happen
00:23:57We campaigned for Donna to get here
00:23:59Now we just need for those responsible to be held to account
00:24:04All reviews will get this multi-professional assessment
00:24:09And they'll be graded zero if the team feels that care was appropriate
00:24:15To grade three if there were major concerns
00:24:19In which in all likelihood different care would have changed the outcome
00:24:24The original families who campaigned so hard
00:24:28They all met the terms of reference and they're all within the review
00:24:32So that room
00:24:36I think I would like just to sort of refresh what it is that you are doing
00:24:42We will consider all of the evidence that is possibly available
00:24:48Medical records are a large part of that
00:24:51Family testimonies
00:24:52Governance and risk information
00:24:55It all comes together in one big jigsaw
00:24:57And you know Family Voices
00:24:59I know you know this
00:25:01Runs absolutely central right through the review
00:25:05I guess after meeting all the families
00:25:08Yeah
00:25:08What I really want to know is when
00:25:10When you know
00:25:12Substantive change is going to be made
00:25:15And when care is going to be safe again at NUH
00:25:18Okay
00:25:19I am seeing a definite intention
00:25:22That families will be listened to
00:25:27And that what families say matters
00:25:30With that in mind
00:25:32Families want to understand what an apology would look like
00:25:35A proper apology
00:25:37Not a reiterate our condolences
00:25:40Okay
00:25:40Okay
00:25:41Just talking specifically about Harriet and I
00:25:45Then we have given you evidence that we have and stuff
00:25:48And whether there is anything more that we can give you to develop per case
00:25:52What would be really helpful to my review team
00:25:56Would be a timeline from your perspective
00:25:59You know what you want the review to understand and highlight
00:26:03Is the huge amount of review that you put into
00:26:06And trying to tell the trust
00:26:09Very soon after Harriet died
00:26:11About the problems that they had
00:26:14And then as you have explained to me
00:26:16How compounded your grief was
00:26:18When you kept being pushed away
00:26:19Pushed away
00:26:20There is nothing here to look at
00:26:21You wrote to X on such and such a date
00:26:24You wrote to Y
00:26:26You wrote to Z
00:26:26You wrote to A
00:26:27You wrote to B
00:26:28Yeah
00:26:28That would be extremely helpful to my team
00:26:32These are all the emails that I'd
00:26:44Wow
00:26:44I'd find
00:26:45So we just need to print out the emails from that
00:26:48Yeah
00:26:50So look at these emails all to the medical director
00:26:53Yeah
00:26:54And that meeting
00:26:56I mean it's all recorded
00:26:57But we totally blew the whistle there
00:26:59And this is the stuff for Donna
00:27:02Because it is
00:27:03It describes a clear timeline of people being told
00:27:07And failing to respond in a way that changed things
00:27:10I mean look at this
00:27:12We have considered all relevant incidents since December 2015
00:27:15To date 10 of these cases have been reported as SIs
00:27:18There are different categories of incidents
00:27:23You have standard incidents and then serious incidents or SIs
00:27:29Which have to be investigated
00:27:31Any serious incidents or hospital is reported to the Department of Health
00:27:39Who assess the safety of a hospital
00:27:41At Nottingham they invented a whole new category called a high level incident
00:27:46Which does not get reported
00:27:48And the medical director has downgraded so many cases
00:27:54And that's frightening
00:27:57I'm used I guess to people taking me seriously
00:28:17To have that so fundamentally ignored is difficult
00:28:22We do not consider the threshold for such referrals have been met
00:28:26It's not right is it
00:28:28One of the things that's been really challenging is being not believed
00:28:33And so I've made notes, conversations
00:28:37What I'm hoping is that it becomes something for the police
00:28:42And for the courts
00:28:45Because the regulators have not wanted it
00:28:49Oh here we go
00:28:50Have you informed the police that there has been a death
00:28:52A completely normal baby to completely healthy parents
00:28:56Respectfully Harriet was not a completely normal baby
00:28:59At post-mortem there was evidence of S-ending infection
00:29:03And a recognised cause of stillbirth
00:29:05We do not consider that there has been any criminal act
00:29:09Or admission to prompt us to report Harriet's death to the police
00:29:12There was no infection was there
00:29:17And you were a physio
00:29:24Yeah
00:29:26Which I loved
00:29:27Loved my job
00:29:28Worked really hard
00:29:30So both Sarah and I lost our jobs
00:29:34Now they will say it's for other reasons
00:29:36But we're clear
00:29:37It's because we were blowing the whistle
00:29:38I got a letter from my employer
00:29:44Asking about my non-attendance
00:29:47And the HR lady said that she would continue to pay me
00:29:52Until two weeks after Harriet's funeral
00:29:55And then I'd stop being paid
00:29:57Obviously our legal team challenged that
00:30:00I was off sick
00:30:03And then out of the blue got an email from the medical director
00:30:06Saying, dear Jack
00:30:08Can you please make an appointment
00:30:10So that we can discuss your obligations to the trust
00:30:13We had that meeting
00:30:16And we spent most of the meeting whistleblowing
00:30:18And then at the end of it
00:30:20He said, I'm sorry
00:30:21But you're not going to have a job
00:30:22For much longer
00:30:23So let's agree that your last day is
00:30:25Well, it was December 2018
00:30:27You know, I always say it
00:30:31But to put it frank
00:30:33You know, they killed our daughter
00:30:35They've ruined our careers
00:30:37And they've ruined our lives
00:30:39It's okay
00:30:58You're right?
00:30:59Yeah
00:30:59Nice to see you
00:31:00And you
00:31:01Hello
00:31:01You've grown
00:31:03He's just woke up
00:31:04He looks like me when I just woke up
00:31:06How are you?
00:31:09Okay
00:31:10Yeah
00:31:11Yeah
00:31:11This is
00:31:12Um
00:31:14Hard
00:31:15Hey, Al
00:31:16Hello, mate
00:31:17Sorry
00:31:17It's been a while
00:31:19It's been very hectic for us
00:31:20Yeah, I know
00:31:21Yeah
00:31:21So you're moving?
00:31:23Yeah
00:31:24Yeah
00:31:24We just don't feel safe here, to be honest
00:31:26Yeah, I feel like a voyeur in your life
00:31:29You tell me so much
00:31:30If it wasn't for you
00:31:31Then there'd be no-one listening to us
00:31:33I remember standing in that kitchen
00:31:35And when I was first speaking to you
00:31:36The first time that someone had believed us
00:31:39Yeah
00:31:39You understand?
00:31:40Yeah
00:31:40I do
00:31:40You don't realise what you've done for us
00:31:42You really don't
00:31:43Thank you
00:31:43You're doing good stuff too, by the way
00:31:46This is fighting that you're doing
00:31:50And everybody that shoulders this burden
00:31:53Moves it on a little bit
00:31:55What's your background again?
00:31:57Because you say you know about ventilators
00:31:59So I was working with children with complex health conditions
00:32:04Okay
00:32:04Um, so
00:32:06Nighttime, CPAP and that sort of stuff
00:32:08Yeah
00:32:08There are some people who I think
00:32:16Already want to share their experiences
00:32:19Amma and Sharma
00:32:21Are you comfortable to
00:32:22Yeah
00:32:24My name's Sharma Thomas
00:32:27Um
00:32:28And I'm here to share mine
00:32:31And my partner
00:32:32Amma Maduwako
00:32:33Um
00:32:34Our experience
00:32:36At Nottingham City Hospital
00:32:37Um
00:32:39So
00:32:40From the moment our twins entered this world
00:32:44We raised our voices in concern
00:32:48To the nurses and to the senior management
00:32:50He labelled us as parents
00:32:52Who didn't want our kids to have oxygen
00:32:55I forced sinners through a five month
00:32:59Child protection investigation
00:33:01This left us unable to mourn
00:33:06For the loss of our daughter
00:33:07She was four months old
00:33:12Spent her entire life
00:33:14Confined to a hospital bed
00:33:16I don't know
00:33:30Amma, we've got some vital stuff
00:33:33That needs to happen
00:33:34Um
00:33:34Donna needs us to collate our evidence
00:33:38And get it to her
00:33:39Can you do that before you move away?
00:33:42Yeah
00:33:42Every email, meeting memo
00:33:44Phone call memo
00:33:46Everything
00:33:46Yeah
00:33:47Yeah, we were concerned about a ventilator
00:33:50Because, um
00:33:51Our concerns were that they were misusing
00:33:53The pressures
00:33:54I raised a question about the ventilator
00:33:57Machine wasn't working
00:33:58This is what I'm saying
00:33:59And they were trying to fix it
00:34:00They were stood there
00:34:01Yeah
00:34:02Like, like, how is this not in front of the coroner?
00:34:04They haven't told the coroner that
00:34:05Yeah
00:34:05They haven't told the coroner
00:34:07What they did after this event
00:34:08Was they went and reported on the social services
00:34:11Yeah
00:34:11And said we were, we're refused the medical treatment
00:34:13We were actually in the hospital
00:34:14Going through the discharge and planning
00:34:17Yeah
00:34:17And then she dies
00:34:18She died on the 25th January
00:34:20So they delayed her release
00:34:22Because the social services was trying to
00:34:24Basically get a court order against us
00:34:27I mean, we just wanted clarity
00:34:28On what treatment the hospital were giving Adora
00:34:30But the hospital interpreted that
00:34:32As us refusing treatment
00:34:33Oh, bless you
00:34:41Right, thank you for looking after me
00:34:47Just about
00:34:48Right, she'll leave you to it
00:34:52Ta-da
00:35:03Yeah
00:35:04Hey
00:35:05Uh, come on
00:35:22That stuff I'm printing now is in evidence
00:35:31You know what I'm saying
00:35:31Have you got the medical note
00:35:38Where they, where, um
00:35:40They review Adora's machine
00:35:42Um
00:35:43What do you need me to send it to you?
00:35:45Yeah, could you send me that?
00:35:46That's pretty key evidence
00:35:47You know when they first put her on the ventilator?
00:35:55When it went wrong, yeah
00:35:56When it went wrong
00:35:57And then they didn't tell the coroner
00:35:58On a document
00:35:58So they've said that they don't know what caused it
00:36:00That's what
00:36:01And then you have the nerve to tell the coroner
00:36:03That I caused harm to my daughter
00:36:04Knowing that we're bereaved parents
00:36:06Maybe we should try and call the coroner's office again
00:36:11They're not going to talk to us
00:36:13Might be worth a try
00:36:15That's if they even pick up
00:36:22Coroner's office
00:36:24Hi, hi, um, I was wondering if I could speak to a representative
00:36:28Who's calling?
00:36:31Uh, my name's Amma Maduwako
00:36:33And what's the name of the deceased?
00:36:38Uh, Adora Maduwako
00:36:40And have you got the date of birth, please?
00:36:45Yeah, it was 5th of September 2022
00:36:47Just bear with me, I'll just pop you on hold
00:36:52Okay
00:36:53When it comes to NUH
00:36:56Like, not everything's about race
00:36:58But some things are about race
00:37:00Yeah
00:37:00Like, think about it
00:37:01Jack, he's done so well
00:37:03Done so much for us
00:37:03So much for all the families
00:37:04But they're listening to him
00:37:06Yeah
00:37:07Why?
00:37:08Because he's a doctor
00:37:09He's reputable
00:37:10Who am I going to listen to?
00:37:1320-year experienced doctor
00:37:14Or black guy from London
00:37:15If it wasn't for someone like him
00:37:17Being the spokesperson
00:37:19Then why should they listen to us?
00:37:22Yeah
00:37:22Like, it sounds harsh
00:37:23But that is literally
00:37:24What it boils down to
00:37:26Yeah, that's what they do
00:37:39They do that all the time
00:37:40Yeah
00:37:40That's literally like the 5th time
00:37:43They've done that
00:37:43Usually they'll just respond
00:37:45And be like, oh yeah
00:37:46We're not talking to you
00:37:46But they just started hanging up
00:37:48That's what they do
00:37:49Yeah
00:37:49He's conked out
00:37:52You know
00:37:53Let me get him a blanket
00:37:55Okay
00:37:56Go on, have baby Dora's blanket
00:37:58You alright?
00:38:05Yeah, just seeing her blanket
00:38:07Yeah
00:38:08Because like, he looks like her
00:38:10When he sleeps
00:38:12So
00:38:25You've been told
00:38:32You're just one of those things
00:38:33Babies die sometimes
00:38:35They don't
00:38:36Because it isn't
00:38:38One of those things
00:38:39Babies shouldn't just die
00:38:40I will always talk about my son
00:38:44And I will always tell his story
00:38:45Because I was blamed for his death
00:38:49For that long
00:38:50That I actually started to believe
00:38:52I'd done it
00:38:52And I started to believe
00:38:55That I didn't deserve
00:38:56My other five children
00:38:57I thought
00:38:59They've covered up
00:39:00And lied on
00:39:00All of my situation
00:39:02Eight years on
00:39:03I'm meeting families today
00:39:05That have been told
00:39:05As I was
00:39:06It was my body's fault
00:39:08That was a lie
00:39:09They are trying their hardest
00:39:12To gaslight
00:39:13And to misrepresent
00:39:14But
00:39:16There's nothing they can do or say
00:39:18That can change
00:39:19What I know to be reality
00:39:21Because I was there
00:39:22And we witnessed it
00:39:23Right
00:39:36Where should I do this one
00:39:37What background
00:39:39Out there
00:39:40Something different
00:39:41Can't stop humming
00:39:43Peppa Pig
00:39:44Hello
00:39:45Yay
00:39:48Well done
00:39:50Hello
00:39:52Having our Facebook group
00:39:58Of bereaved and harmed families
00:39:59Means we can quickly update everybody
00:40:01With information that might help
00:40:03With their cases against NUH
00:40:05Happy?
00:40:10One of the main things
00:40:11Well you can talk about Harriet
00:40:12And say we didn't get a
00:40:13Look for a prosecution
00:40:15Because of this three year limit
00:40:16That we weren't aware of
00:40:17So just to make sure
00:40:18Everyone is aware of this
00:40:19Yeah
00:40:19And how to contact them
00:40:21Hello
00:40:22This is a video about
00:40:23The Care Quality Commission
00:40:25And what they should be doing
00:40:27And how to access them
00:40:31And why
00:40:32What they do is they
00:40:34Insect
00:40:35Give out ratings
00:40:36And they
00:40:39Also prosecute
00:40:41So they are responsible
00:40:42For prosecuting
00:40:43The hospital
00:40:43And the hospital staff
00:40:44But there's a key piece
00:40:46About this
00:40:47Is the law
00:40:48Is that they have three years
00:40:50To prosecute
00:40:51If you are within that three years
00:40:54Act
00:40:55And do it loudly
00:40:56And clearly
00:40:58This rule is appalling
00:41:01Three years is nowhere near long enough
00:41:03And to not let people know
00:41:05Yeah
00:41:06Is awful
00:41:07Yeah
00:41:09I mean it's survival
00:41:12For the first couple of years
00:41:13Isn't it
00:41:13Yeah
00:41:14And survival even if the hospital
00:41:16Have done a great job
00:41:17And are communicating with you
00:41:18You're not
00:41:19Survival
00:41:20And then you've got to
00:41:21Site
00:41:21A
00:41:22Massive system
00:41:24I believe
00:41:27They're a failed organisation
00:41:29How can you have
00:41:31So many baby deaths
00:41:32And you are responsible
00:41:34For prosecuting them
00:41:35And yet
00:41:37There are only two prosecutions
00:41:39Against maternity units
00:41:40In the UK
00:41:41It's fair to say
00:42:05We all believe
00:42:06The CQC
00:42:07Must have deliberately
00:42:08Run down the clock
00:42:09In order to avoid prosecution
00:42:11Because there have been so few
00:42:13I don't think he understood
00:42:21Just how much we had
00:42:23And how much we knew
00:42:24Do you know what I mean
00:42:26He came across as very much like
00:42:27This is just a bunch of families
00:42:29That think they know it all
00:42:30Until we started talking
00:42:31And then he was like
00:42:32Wow
00:42:33I really need to like
00:42:35Just sit back a minute
00:42:36Because they know what they're talking about
00:42:37And that's the thing
00:42:38They underestimate us as families
00:42:40We'd blown the whistle in there
00:42:42With the chief executive of the CQC
00:42:44Did you notice though
00:42:45As a regulator on that whole
00:42:46The CQC
00:42:47That every one of those in that room
00:42:48That he had failed
00:42:49To deliver
00:42:51On the prosecution
00:42:53Have you been given an apology?
00:42:55No
00:42:56He didn't
00:42:57No
00:42:57I guess from my point of view
00:42:59Hearing that
00:43:01The things that happen to us
00:43:04That are criminal
00:43:05The failure to be candid with us
00:43:09And Harriet's avoidable death
00:43:11Stand no chance of having a prosecution
00:43:13Brought by the CQC
00:43:15Means that
00:43:15I wonder if we need to bring a prosecution
00:43:17Then against the CQC
00:43:18Because it was their failures
00:43:20To act
00:43:21Not ours
00:43:22We told them
00:43:23You know most people told them
00:43:25And they just did nothing
00:43:26Yeah they felt it
00:43:27And then that's not our fault
00:43:28The real key thing here
00:43:30Is actually people have deliberately
00:43:31Run down this three year clock
00:43:34To deny you
00:43:35Access
00:43:36Access to that justice
00:43:38Yeah
00:43:38I'm just really sorry
00:43:40You know
00:43:40For Winter's case
00:43:42We got a prosecution
00:43:43But just hearing your stories
00:43:45Where you're
00:43:46The clock's deliberately been run down
00:43:48Winter Andrews died in her mother's arms
00:43:54She lived for just 23 minutes
00:43:57Nottingham University Hospital's NHS Trust
00:44:01Has received a fine of £800,000
00:44:05This is the first time
00:44:09That Nottingham University Hospital's NHS Trust
00:44:12Has ever been criminally prosecuted
00:44:15I am the mum to Winter Andrews
00:44:20Who died in 2019
00:44:21At Queen's Medical Centre
00:44:23After Winter died
00:44:27We were in the bereavement suite
00:44:28When the coroner rang us
00:44:30And the coroner said
00:44:31I've been looking at your notes
00:44:33From when you came in on Sunday
00:44:34And I said
00:44:35I didn't come in on Sunday
00:44:36I came in on Saturday
00:44:38At which point
00:44:39The coroner realised
00:44:41That the trust hadn't sent
00:44:42All the correct records over
00:44:44We later
00:44:46At inquest
00:44:47Discovered that they'd actually
00:44:48Ticked the box
00:44:49To say that Winter's death
00:44:50Was an expected death
00:44:51Winter was a perfectly healthy baby
00:44:53There was no reason
00:44:55For her to die
00:44:56The coroner ruled
00:44:58That she died
00:44:59Due to the neglect of the trust
00:45:00The trust failed
00:45:02To care for us properly
00:45:03Had the coroner
00:45:06Not rang me
00:45:07In the bereavement suite
00:45:08And had I not said
00:45:09We came in on Saturday
00:45:11The coroner would have signed
00:45:13Winter's death certificate
00:45:14They would have handed it out
00:45:16And Winter's death
00:45:17Would have gone uninvestigated
00:45:19This is only one of two prosecutions
00:45:26That the quality care commissioners brought
00:45:28Against a maternity unit
00:45:30The common word used by the judge
00:45:33About this hospital was failure
00:45:35Over and over again
00:45:37The baby daughter of my constituents
00:45:41Gary and Sarah Andrews
00:45:43Died just 23 minutes
00:45:45After she was born
00:45:47When they asked questions
00:45:49About that
00:45:50The parents were told
00:45:52That these things happen
00:45:53And that if they had to listen
00:45:56To the concerns of every mother
00:45:58They would be overrun
00:45:59Thanks to dogged campaigning
00:46:03By Gary and Sarah
00:46:05And other parents
00:46:06Whose babies had died avoidably
00:46:09Nottingham University Hospitals Trust
00:46:12Was found to have systemic failures
00:46:14And last week was given the highest
00:46:17There's so many red flags
00:46:18Around the safety of this service
00:46:20Three and a half people
00:46:24With very serious outcomes
00:46:26Every week
00:46:27In a department
00:46:28That says
00:46:29Nothing to see here
00:46:30So
00:46:37You told Harriet
00:46:40That
00:46:41That she was taken away
00:46:45Well no
00:46:48She would be in the
00:46:49Cold cot
00:46:50They asked if we wanted her to sleep
00:46:53In the room
00:46:53But I couldn't
00:46:54Like during the night
00:46:55But I couldn't handle that
00:46:58So
00:46:59Sorry to be blunt
00:47:01But she'd be in the freezer
00:47:02A bit there
00:47:02And then when we wanted to see her
00:47:04Then she'd come out
00:47:05They asked if we wanted a post-mortem
00:47:15They were quite non-fussed about it
00:47:20If we don't want her to have a post-mortem
00:47:22We don't have to
00:47:23But we did because we needed an answer
00:47:26We didn't want them to blame her
00:47:27I don't know how long it was
00:47:32It must have been like 10 days or something
00:47:34Whilst her post-mortem was being arranged
00:47:35So we still had access to her
00:47:38Which felt so normal
00:47:41And her skin was soft
00:47:43And she had a crooked toe
00:47:47Which had been causing new difficulties
00:47:49Through the late stage of pregnancy
00:47:51Because it was stuck under your
00:47:53Right under my rib
00:47:54Under your rib
00:47:55She had one slightly crooked toe
00:47:57Which we assumed was that
00:47:58When she went for post-mortem
00:48:04That was the last time we saw her
00:48:06You read her a book and stuff
00:48:12I did
00:48:13I remember holding her
00:48:16Just wishing that she would come back to life
00:48:22Couldn't understand it
00:48:23And yeah, we read her that book
00:48:26I love you to the moon and back
00:48:28And then we said goodbye to her
00:48:32And we put her down and left that room
00:48:36And walked out there
00:48:38I remember
00:49:05The pain was extraordinary
00:49:07The pain of her not being alive
00:49:10And the pain of
00:49:11You killed my daughter
00:49:13You've covered it up
00:49:15And you accused her and us
00:49:17And yeah, didn't want to be around
00:49:20So yeah, pretty dark days
00:49:22But there's still a bit of me
00:49:26That just thinks
00:49:27I'm a doctor
00:49:29Why on earth
00:49:30Did I allow this to happen to my family
00:49:33I've failed to protect my family
00:49:35The reality is that I was 100% in their care
00:49:41The parents of a baby girl who died after mistakes by maternity staff in Nottingham
00:49:58Say they'd give back the settlement awarded for negligence to have her back
00:50:03Jack and Sarah have been awarded £2.8 million
00:50:08Thought to be the largest payout for a stillbirth clinical negligence case
00:50:15When did you put him a claim?
00:50:19We met that barrister around August, September of 2016
00:50:24Yeah, he told us
00:50:28We didn't have any psychiatric issues
00:50:30We'd get a standard £10,000 for a stillbirth
00:50:33And we wouldn't get any change at the hospital
00:50:35But that's another thing
00:50:36Like we wouldn't have done that
00:50:37It was literally to get answers
00:50:39And then, you know, you do go down this route of
00:50:42Well, the only way they respond is
00:50:43Financially, that's what hurts them
00:50:46They don't give a shit about anything else
00:50:48Oh
00:51:06Come on
00:51:09Can you come and bounce it, my feet?
00:51:12Yep, hold on
00:51:14Say two monsters
00:51:25I can see your toes
00:51:28Ah, two monsters
00:51:30I stress by Lottie
00:51:33I feel it's much more difficult to talk about
00:51:39Harriet now because I feel that Lottie's innocence has just been completely stolen from her
00:51:46So it's not just me and Jack, it's her
00:51:55You know, a childhood of growing up with a dead sister who should be alive
00:51:59Just put it on me gently
00:52:01I worry I get that balance wrong
00:52:04We do talk about Harriet
00:52:05Oh, look at that
00:52:07That's like a pink finger monster
00:52:09I think now I've had Lottie
00:52:15I grieve the missed milestones with Harriet too
00:52:19You know, I've seen Lottie's first steps, I'll never see Harriet
00:52:22You know, I'll see Lottie go to school
00:52:25I haven't seen Harriet go to school or anything like that
00:52:30And it just adds an extra layer onto your grief
00:52:36It's just so painful sometimes to let my mind even wander there
00:52:40Let's wipe your hands please
00:52:46And your feet
00:52:47Stand up here
00:52:49One of the things I was thinking about was
00:52:53The impact of it then
00:52:56On the two of you
00:52:58In your relationship
00:53:01Um
00:53:07Yeah, it's been really difficult
00:53:12Right
00:53:15These are made with your homegrown tomatoes, Lottie
00:53:18Yep
00:53:18Good eating
00:53:21Proper Italian
00:53:24I feel like after Harriet died
00:53:29I made sure that, you know, Jack was involved and everything like that
00:53:34Because it's so easy for fathers not to be involved
00:53:36Mmm
00:53:37And then I feel like it got to a point where
00:53:40I wasn't recognised
00:53:42What I'd been through
00:53:44And I just felt really alone
00:53:49Keep it up if you want
00:53:51Um
00:53:57Jack's response would perhaps be more impulsive than mine
00:54:00So he'd want to email people straight back
00:54:01Whereas I reflect a bit on it
00:54:03Then that just made me really anxious
00:54:06Hello
00:54:07Oh, hold on, let me just clean this paint up first
00:54:09I do, yeah
00:54:09I felt like every day there was some confrontation
00:54:12With the hospital or with someone else
00:54:15Oh my goodness
00:54:18Look at that
00:54:19Wow
00:54:21Wow
00:54:22This is turning into a spot
00:54:24I kind of thought it was just with one senior midwife to put our views across
00:54:28But it will be
00:54:29I find it easier to deal with conflict and confrontation
00:54:34And I found it quite difficult to not be able to do it
00:54:40That left me very stressed
00:54:42You know, we need to be solving this now
00:54:44That's not a meeting that I want to be in at all
00:54:49And I don't think it's appropriate for us to meet with them
00:54:51Yeah
00:54:52Just two very different ways of doing it
00:54:56Yeah
00:54:57You've been involved in something very intense
00:55:03Ongoing
00:55:04You've put a lot of effort into it
00:55:06But the impact is that you don't live together anymore
00:55:11Yeah
00:55:12And haven't for nearly four years
00:55:15Mmm
00:55:16Mmm
00:55:18Lottie was born
00:55:21We separated
00:55:22I can't remember, Lottie
00:55:24This little piggy went to market
00:55:33Today marks one year since the review led by senior midwife Donna Ockenden began
00:55:38It's the largest maternity review of its kind
00:55:41With 1,800 families involved
00:55:43The staff and managers and former managers aren't compelled to come forward to your inquiry, your review, are they?
00:55:55The very clear message from me is that I am expecting all current and former staff who receive a formal letter from me to cooperate
00:56:07In the unlikely event that anyone decides not to cooperate with me, I will take this to the top of the NHS and if necessary to government
00:56:22I think if it wasn't for our connections nobody would have told us some of the stuff that they've told us
00:56:28But then those people won't speak up
00:56:33Without whistleblowers it becomes a more difficult review
00:56:37Nottinghamshire police has said it will launch a criminal investigation into failures in maternity care at the city's hospitals
00:56:56Holly, how is this police investigation likely to affect Donna Ockenden's ongoing review into maternity services at Nottingham's hospitals?
00:57:09Speaking earlier today Chief Constable Kate Maynell says she wants to work alongside the review whilst not hindering its progress
00:57:15Donna Ockenden expects her review to take at least 18 months
00:57:22For those who've lost loved ones though, it's a step closer to getting the answers they need
00:57:28So as of yesterday we had 1,813 families who are actively involved in the review
00:57:34In 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
00:57:49We've got 720 staff who are now in contact with us
00:57:54The government fully endorsed my work in March 2022
00:57:59We're two years down the line
00:58:01There is still an awful lot for government to do right here and now to improve maternity services for all mothers in England
00:58:08A lot of families met in person some for the first time a few weeks ago to share their experiences
00:58:13What do you think is the benefit in families doing that?
00:58:17What families said to me was that there is something very powerful
00:58:21And some families said healing
00:58:24That they, you know, realised many of them for the first time that they weren't on their own
00:58:29It wasn't just them
00:58:30Families told me how the harm to their babies and their children had broken them
00:58:38Marriages and relationships simply haven't survived the stress and distress caused by maternity harm
00:58:48Back in November, I did a number of home visits and met families face to face here in Nottingham
00:58:55Hearing of discrimination, of racism, of some staff being dismissive and unkind
00:59:03We will not tolerate this behaviour
00:59:07This is just family stuff
00:59:12It just doesn't feel like it can be a home for us anymore
00:59:19I just don't feel safe living in a city where they have a hospital system like this
00:59:27They have a social services system like this
00:59:29And you can be falsely accused
00:59:32These are, um, yeah, you haven't seen these have you?
00:59:52No
00:59:53These were a 3D cast
00:59:57A 3D cast
01:00:19Can you get a cloth so I can clean it?
01:00:22Ich bin froh, dass wir nicht in den Stoffen gehen können.
01:00:52Untertitelung des ZDF für funk, 2017
01:01:22So 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.
01:01:39Got Nick and Anthony here, so can I just say over to the families?
01:01:44So thank you so much for doing something that is remarkable and remarkable in the setting of not having anything like this before.
01:01:58When 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.
01:02:08Now that the numbers have trebled, that's become increasingly important.
01:02:13So it's probably somewhere between £1.5 and £2 million worth of resource every year because it's a very big review.
01:02:19What them staff members need to understand is, they're talking to somebody whose baby dies.
01:02:27So we're going to shout, we're going to scream, and then it's, we're the bad people.
01:02:32And I'm not, I just want answers.
01:02:35And 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.
01:02:42I think in some senses for us as an organisation, it's important also we're clear where we've failed and what we're apologising for if we're going to rebuild.
01:02:51We've had an official apology from your predecessor, and I can assure you it changes absolutely nothing.
01:02:58What I want as a mum is to know that those midwives who have done it to all of these mums are really trained or held to account.
01:03:07If I may, can I just say what we've said again?
01:03:09Yes, yes.
01:03:10So, I said, let me be very clear that as the public record shows, in the area of maternity services,
01:03:18there are where we've failed the families and communities that we exist to serve.
01:03:22To make matters worse, having failed them, we have too often worsened things by not responding to them appropriately.
01:03:29Some families who we've had the chance to meet have told us they want a meaningful apology,
01:03:33that they recognise as meeting their needs, including accountability and a change in the culture.
01:03:39Now, you may still feel it's not the right time, but I think it's important that is discussed.
01:03:45OK.
01:03:46And probably discussed outside of here.
01:03:47Just three points I'd like to add in. I just want to get it in the final apology.
01:03:51I want you to apologise for victim blaming.
01:03:54I want you to apologise for gaslighting. And I want you to apologise for the cover-up.
01:04:00That's what I would like in the apology. Because that's all evidenced.
01:04:03I think it's incredible that you have changed a board who have sat some of them for a very long time.
01:04:25It just shows that you've listened to us.
01:04:27Yeah.
01:04:28Oh.
01:04:29That's impressive.
01:04:31Wow.
01:04:32Yeah.
01:04:40The struggle to get an independent, proper review in Nottingham was awful.
01:04:47I don't know.
01:04:47I'm sorry.
01:04:48Now, we have the review and the police are investigating.
01:04:59I want to see people in court for the death of my daughter and so many other babies and mothers.
01:05:06This is just the beginning.
01:05:14We are not done.
01:05:15We are not finished.
01:05:17And we will not stop until that happens.
01:05:23Tickle me.
01:05:25Tickle.
01:05:25Tickle.
01:05:29What does she have to do?
01:05:31What does she have to do?
01:05:32What does she have to do?
01:05:32We still spend a lot of time together.
01:05:34I think we have some really good times together.
01:05:38I think we have some really bad times together.
01:05:46They just exposed how different we are, which is, I suspect, how everybody might be if their child died.
01:05:57You think you're similar.
01:05:58Yes.
01:05:59But wait until you have to deal with this and then leaving the cap off the toothpaste tube becomes divorce material.
01:06:08Because it's an awful lot to put people through.
01:06:11And, you know, I hold individuals responsible for my daughter's death,
01:06:19for my mental health,
01:06:23for my mental health,
01:06:23my marriage.
01:06:27In order to start healing,
01:06:32we need justice.
01:06:33We need justice.
01:06:35Amen.
01:07:05Amen.
01:07:35Amen.
01:08:05Amen.
01:08:35Amen.
01:09:05Amen.
01:09:35Amen.
01:10:05Amen.
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