As Nottingham University Hospitals NHS Trust (which encompasses the Queen's Medical Centre and Nottingham City Hospital) continues to face scrutiny and criticism for its poor maternity care via the biggest maternity inquiry in NHS history, we review yet another tragic case of preventable baby death.
Baby Teddy Martin
Baby Teddy Martin, born on 2 August 2023 at 31 weeks at QMC Hospital in Nottingham, was born with a genetic condition (Beckwith Wiedemann Syndrome) which causes a large tongue and makes breathing difficult.
He was admitted to the NICU (neonatal intensive care unit) given his prematurity and medical complications and was kept on a ventilator to support his breathing. Whilst on the ward, Teddy had to be resuscitated several times due to failed extubations (removal of an endotracheal tube).
It was established that Teddy had a 'difficult airway' due to his large tongue. This resulted in difficulties when attempting to take him off the ventilator.
Improper conduct and insufficient planning
On 5 September 2023, an attempt to change Teddy's oral tubing to nasal tubing was made. This was carried out by a junior doctor who had never carried out the procedure before, and without due consideration for Teddy's condition in order to anticipate and plan for potential complications. As a result, when the procedure went wrong, there were inadequate measures in place for resuscitation.
The procedure was indeed met with complications and due to the lack of planning, Teddy deteriorated rapidly. Resuscitation was unsuccessful and tragically, Teddy did not survive.
Following Teddy's death, the Trust commissioned a Patient Safety Incident Investigation (PSII). It was critical of the care given to Teddy and identified that his death was avoidable. This was due in large part to the lack of planning prior to the procedure which failed to take in to account Teddy's vulnerabilities and associated risks, meaning the clinical team was wholly unprepared when the procedure encountered complications. It set out several learning opportunities to improve care.
Having reviewed the evidence (including the PSII), and questioned witnesses, the coroner concluded, that there was not enough contingency planning in place, and the plans to rescue Teddy in the event of a complication were insufficient.
The coroner determined that the cumulative errors made more than a minimal contribution to Teddy's death and that he would have survived had he received better care.
Patient Safety Incident Investigation (PSII)
A PSII is conducted when a clinical incident involving patient care indicates the presence of significant risks and opportunities for learning. It is a process used to understand what happened and why, to learn from it and prevent future incidents.
These investigations are paramount in identifying how and where care fell short to ensure that measures can be put in place, including revision of existing policies, staff training or even implementing new procedures and treatment pathways. This is particularly so in respect of maternity and neonatal care that has fallen short to such an extent that babies like Teddy Martin do not survive.
It is therefore no understatement to say that robust and comprehensive investigations should be the first port of call and a matter of utmost priority in the event of a baby death. These investigations mustensure swift and thorough action with the aim of preventing further deaths and improving patient care.
QMC maternity failings – how many more?
Sadly, Teddy Martin is not an isolated case.
It is in fact one of many deaths arising from inadequate care, highlighting the need for urgent improvement in services throughout the respective Nottingham Trusts.
Donna Ockenden, leader of the Ockenden Maternity Review into the Trusts, continues to investigate maternity failings with the aim of uncovering systemic internal issues within the Trusts that have ultimately led to poor care and resultant baby deaths.
The investigation has so far revealed that some delivered care has been significantly poor such that Nottingham University Hospitals Trust was fined £1.6million in February 2025 following a prosecution by the CQC (Care Quality Commission), This was for its role in the deaths of babies Adele O'Sullivan, Kahlani Rawson and Quinn Parke in 2021. The fine is the largest ever imposed upon an NHS Trust.
It was further announced in June 2025 that Nottinghamshire Police had launched Operation Perth to investigate corporate manslaughter due to the deaths and severe harm of over of, potentially, over 2,000 women and babies in Nottingham.
As the investigations continue, and grieving parents wait for answers, it remains to be seen how many more failings have led to preventable deaths. More must be done.
The people of Nottingham deserve better.
For more information on what to expect in an inquest, you can read our blog 'What happens at a Coroners Inquest'.
Sometimes a coroner will determine an inquest should engage Article 2 of the Human Rights Act. For more information on Article 2 inquests, you can read our blog 'Article 2 inquests: when and why?'
Rothera Bray's Medical Negligence and Serious Injury team have considerable experience in dealing with inquests, including Article 2. If you have lost a loved one and their death is being investigated by the coroner, we can help. Contact us on 03456 465 465 or email enquiries@rotherabray.co.uk
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