A HEARTBROKEN mum has claimed that an NHS admin error may have led to the stillbirth of her son.
Kelly Whitehead, 37, said she informed staff at Queen’s Medical Centre, Nottingham that she was moving from Hyson Green to Clifton in the city and that her phone number would need updating.
Kelly Whitehead believes an admin error may have contributed to her stillbirth at 41 weeks Credit: SWNS
Pictured, the Queen’s Medical Centre, part of Nottingham University Hospitals NHS Trust Credit: Alamy
But after moving she said she discovered her updated details had not been correctly recorded across services and she went without care between the “critical period” of 31 and 41 weeks.
Her son Christopher was stillborn at 41 weeks in April 2019.
Under NHS guidance, women who miss antenatal appointments should be followed up under “did not attend” procedures by offering alternatives such as home visits, liaison and escalated safeguarding procedures.
But, Kelly, who is now bringing action against the hospital, has claimed this did not happen and if she had been in hospital just a “week earlier”, she would still have her son today.
Nottingham University Hospitals NHS Trust, which is already under scrutiny as part of the ongoing maternity Ockenden , acknowledged in a letter to Kelly that “there was a missed opportunity to monitor Christopher’s growth on scan which may potentially have resulted in a missed opportunity to deliver Christopher earlier”.
Kelly said: “I want to make sure Christopher’s name isn’t forgotten.
“The hardest thing to live with is the years I’ve spent blaming myself.
“I will never forget being put into the labour ward, where I could hear the other babies crying and had to lie there thinking my end result was going to be very different.
“It just felt criminal because these are professionals and you trust them – and I felt forgotten by the system that was supposed to help me.
“Planning a for the son I will never have will stay with me for the rest of my life.
“I have been in a state of survival and grief ever since.”
Before Kelly became pregnant with Christopher in September 2018, she gave birth to twins George and Felicity, who were born premature via an emergency C-section.
Due to the traumatic birth, which has left her two children disabled with high-needs , Kelly was informed she would be classed as high risk.
Initially she said, she was provided with extra scans and monitoring which gave her reassurance that everything was progressing well – until she moved out of the local area.
She said: “Neither of my twins weighed more than a small bag of sugar.
“We didn’t know at points if we were going to be able to bring them home.”
Kelly said when she realised she was pregnant again with Christopher, she wanted to push to have a planned C section as she was told it would be safer on her already damaged body.
She said: “I was living in a single bedroom flat at the time, already trying to find somewhere to move to.
“It was scary, we already had two twins with high medical needs.
“But I found a renewed sense of hope in me when I knew Christopher was on the way, that maybe this can be the healing journey I need because I’ve spent so long blaming myself and my body for failing to carry them safely.
“My body is meant to be the safest place for them as far as we’re told, but I wanted another chance to do right by my children.”
Despite going into the hospital asking for a planned c-section, Kelly said she was talked out of it by hospital staff – and left with a pamphlet feeling “half-reassured”.
The 37-year-old said she informed staff at the Queen’s Medical Centre, Nottingham, that she was moving and her phone number would need updating Credit: SWNS What has the Ockenden report into Nottingham University Hospitals found?
IN June, an investigation into Nottingham University Hospitals NHS Trust laid bare one of the biggest and worst NHS scandals in history.
The 400-page report found the deaths of 156 unborn babies and newborns, and six mothers, could have been prevented if the hospital had better looked after them.
At least 350 more were left injured or disabled.
It looked at maternity care at Queens Medical Centre and City Hospital in Nottingham between 2012 and 2025, with some cases dating back as far as 2006.
was ordered by former health secretary Sajid Javid in 2022 and conducted by expert midwife Donna Ockenden.
It included evidence from more than 2,500 families and 800 staff at the trust.
Some of the key findings by Ms Ockenden’s team included:
- “Multiple examples where failures in neonatal care may have contributed to long-term brain injury and adverse neurodevelopmental outcomes” in babies.
- A “bullying and toxic culture” at the trust over years, with “cliques” among staff that were not confronted, resulting in women receiving inadequate care. One member of staff said “bad behaviours and toxic culture were normalised” that was “cruel to women on labour ward.”
- Multiple examples of “poor telephone risk assessment” of women ringing in with concerns, and a “culture of discouraging women to attend in-person”.
- Incidents were “frequently graded too low” and closed, contributing to the “under-recognition of serious harm and limiting escalation to serious incident investigation”.
- Inadequate communication for women whose first language was not English. Staff described racism and “racist attitudes towards black women labelled too loud, too demanding”.
- Some patients received phone calls when they should have been seen in person. “In several cases the consequences of these failures were severe and irreversible.”
- Staff described routinely working “beyond safe capacity”.
- Some patients described inadequate pain relief, with one saying “It felt brutal… traumatic… they were screaming at me… ‘you need to pull yourself together’…”
She said: “They told me the VBAC was the best option but I wanted a c-section because I knew the recovery is the one I had done before.”
A VBAC stands for vaginal birth after caesarean and is an option for some women who have had a previous c-section.
According to the NHS, three in four women who have had one c-section and then have a straightforward pregnancy are able to have a successful VBAC.
Kelly said: “I remember leaving that room feeling as though I had been talked out of something I wanted so strongly to happen.
“They weren’t listening to me.
“I felt they were cost cutting and talked me out of it because of the cost of a c-section which required several trained members of staff.”
Not long after, Kelly moved to a larger council house in Clifton, the other side of Nottingham.
She then went into the hospital for a general appointment and provided the front desk with her new address and telephone number.
Around half way through her second trimester, Kelly began struggling to keep up with caring for her seriously unwell twins and settling into her new flat alone.
Kelly said: “I was really struggling and getting more and more tired.
“I missed a few appointments because I couldn’t get there on – but when I tried to explain my situation they didn’t seem to care, it just felt like, ‘oh come to your appointments and get on with it’.
“I soon felt as though I fell through the cracks.
“Signposting could have happened, they could have offered home visits but they didn’t make that happen – and I now have discovered they were sending letters out to my old address this whole time.
“Community services were apparently sending home visits out to my old address too, and recording it as no one in – they didn’t even bother to check, call or ask neighbours.”
Kelly said she tried to contact both the hospital and GP practice numerous times to no avail.
She said: “I was just getting ping-ponged back and forth – my GP told me I wasn’t even on their records as a patient anymore.
“It was painful and I felt forgotten and alone – so I stopped trying after a while.
“I thought things seemed fine, and I’ll wait for next appointment – not realising the hospital hadn’t updated that either.
“I felt like I was hitting up against a brick wall.”
As her pregnancy progressed, Kelly began to worry something was wrong.
Donna Ockenden during a press conference for the publication of the independent report into maternity care at Nottingham University Hospitals NHS Trust Credit: PA
Kelly Whitehead had hoped her second pregnancy would be the time “everything went right” after the premature birth of her twins Credit: SWNS
At almost 42 weeks pregnant, with no signs of labour, Kelly claimed she called the hospital again and spoke with someone from the birthing unit at the hospital on the phone.
She said: “I knew the baby had turned and shifted and was sitting lower, I thought maybe I had a sign of mislabour, but when I spoke with this nurse they said it was Braxton hicks – sporadic, practice uterine tightenings that prepare your body for labour.
“I didn’t know the difference.”
When Kelly called again just days later, she said she was told to come into the hospital – but they could not see her on that day, only the day after.
When doctors tried to find Christopher’s heartbeat and failed, they informed Kelly he had been stillborn.
Kelly said: “My world fell apart.
“The hardest part was hearing that as far as they could tell, he had only been dead a few days.
“I believe if I’d been seen a week prior, he would still be there.”
In a follow up letter from the hospital, they said: “Because of the missed appointments, there was a missed opportunity to monitor Christopher’s growth on scan which may potentially have resulted in a missed opportunity to deliver Christopher earlier.”
Kelly added: “I had to lay Christopher in his coffin just before the funeral and dress him in his new baby garments with his little monkey teddy, one that will stay with him forever and one that I keep with me.
“That’s the last act I felt like I could do as his mother: the last time I was ever going to be able to touch or see him.
“I will never forget that – and now I just want to be able to buy him a grave stone.”
Kelly, who has struggled with and grief ever since, is now working with Fletchers Solicitors after she realised her son’s death could have been prevented.
The practice are working with a number of families who have raised concerns about maternity and neonatal care in Nottingham.
Nottingham University Hospitals NHS Trust maternity services remain under scrutiny as part of the ongoing Ockenden Review, which began in 2022.
The Trust is also subject to a separate ongoing into maternity care concerns.
Clinical negligence solicitor Priya Singh, who is supporting Kelly with a legal case, said: “Kelly’s experience is heartbreaking because no expectant mother should go 10 weeks without antenatal care during the final stages of pregnancy, particularly when national guidance is clear that missed appointments should trigger active follow-up and safeguarding measures.
“The Trust has acknowledged missed opportunities in her care, including opportunities to monitor Christopher’s growth and potentially deliver him earlier, raising serious questions about how the systems designed to protect mothers and babies were allowed to fail.
“The Ockenden Review reinforced the devastating consequences that can arise when communication breaks down and continuity of care is lost.
“When a communication failure like this happens, the outcomes can be devastating and Kelly’s experience is a stark reminder that those lessons must be embedded into everyday practice, not simply remain recommendations.
“Families deserve confidence that the changes being suggested will prevent other parents from suffering the same devastating loss.”
Tracy Pilcher, chief nurse at Nottingham University Hospitals, said: “We would like to extend our sincere condolences to Ms Whitehead on the loss of her son, Christopher.
“Following a review of the care provided during Christopher’s birth in April 2019, it was identified that opportunities were missed for community and hospital maternity teams to effectively share information regarding missed appointments.
“We deeply regret that these opportunities were not taken.
“As part of the case review, several areas for learning were highlighted, including the need to strengthen processes, guidelines and procedures relating to non-attendance at appointments.
“We continue to regularly review and improve our procedures and provide ongoing staff training in this area.”
Eze Chidiebere Paul
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