Nottingham Maternity and Neonatal Services

With permission, Madam Deputy Speaker, I will make a statement on the independent review of maternity services at Nottingham University hospitals NHS trust. Donna Ockenden’s review is the largest into a maternity service in the history of the NHS. The nature and sheer scale of the failings it exposes are horrific. It uncovers dangerously and tragically deficient care at almost every turn. Its findings and conclusions are chilling. The report covers 13 years, including accounts from 838 members of staff and, crucially, the experiences of 2,536 affected families. I met a small number of those affected families last week, and I felt numb after hearing the depth of their pain. I felt even more numb when I considered how many families not in the room went through such trauma too, and the forgotten children who survived but live every day with the consequences of maternity care failings. I felt devastated that so many women and babies, as well as their fathers and other family members, had suffered injury, death and lasting trauma while under the care of the NHS. Now having met the families, and having seen the report, I feel appalled by the neglect, incompetence, racism, discrimination, contempt and harassment that so many suffered. I feel heartbroken to know that, so many times, when they tried to raise the alarm about their care, they were ignored, sneered at, disbelieved, blamed and lied to. How on earth could this have happened? There is no single answer, but Donna Ockenden shines a light on what was going on. First and foremost, women were not listened to. Donna Ockenden says that the staff shortages and lack of training in Nottingham were among the worst she has ever come across. Bullying by doctors and senior midwives was rife, which meant that staff who tried to speak up were intimidated and ridiculed. There was a culture of cover-up at the highest levels of the trust, and there were ineffective and inadequate responses from regulators. Perhaps most damning of all, for years the trust ignored evidence of clinical and cultural flaws in both internal and external reviews that it had itself ordered. When I met Donna Ockenden last week, she told me that those inquiries were “diligent” and of “good quality” but that they were effectively swept under the carpet by the board. That refusal to act is unforgivable. Donna Ockenden and her team deserve huge credit for their forensic and compassionate approach, as does my hon. Friend the Member for Sherwood Forest (Michelle Welsh), herself a harmed mother, as well as Members for neighbouring constituencies who have walked side by side with their constituents through years of anguish and struggle. However, the driving force behind the review has been the affected families themselves. They have demonstrated more patience, more courage and more tenacity than one might imagine is possible from those dealing with broken hearts that will never mend. Though each of their experiences is unique, one feature is common: at the very moment when they were at their most vulnerable, they placed themselves and the lives of their unborn babies in the hands of the NHS—and the NHS failed them catastrophically. To all those who have suffered so appallingly, I say today, on behalf of the NHS: I am sorry. I am sorry not just for the failures, or the heartless and undignified treatment, but because your cries of concern went unheard for too long—and so the Government will act. We will act by taking immediate steps, including to expand Martha’s rule to all maternity and neonatal settings so that parents can demand a second opinion if they feel their concerns are being ignored. I know that some people may want me to accept all the review’s recommendations today, but in the past too many recommendations have been accepted and then have sat on a shelf gathering dust, and we have seen more deaths and more suffering. I do not want to let down the families I met in Nottingham, or bereaved parents anywhere else in the country. I want to use the national maternity and neonatal taskforce, which I chair, to create a comprehensive action plan to be published by the end of this year that will address all the national-level recommendations from this review and others. I am confident that work will be welcomed by all those midwives, obstetricians, paediatricians and other healthcare workers who strive every day to make sure that babies are born safely and that women receive outstanding levels of care. It is clear that, in case after case, families felt that regulators, including the General Medical Council, the Nursing and Midwifery Council and the Care Quality Commission, were more concerned with protecting clinicians than with providing accountability. That is damning and that is wrong. As one grieving mother told me: “They put the fox in charge of the hen house.” Clinicians and trust leaders must know that their behaviour will be properly scrutinised and that their actions will have consequences. We must meet the test of the Nottingham victim who told me last week that “accountability drives action”. We are making changes to the CQC, one of which is to extend the cut-off period to initiate proceedings from three to five years so there is more time for families to bring cases. I will also call in the chair and chief executive of the GMC to hear directly their account of the failures at NUH. Let me be clear: if their response falls short, things will change at the GMC. From speaking to families in Nottingham, I know that there is real and understandable anger that some leaders and clinicians at the centre of this review were able to avoid giving evidence. Today, I make a commitment that, when passed, we will use the Hillsborough law’s duty of candour to ensure that witnesses in upcoming reviews of maternity service failures, including those in Leeds and Sussex, can be forced to provide evidence. That change will make sure no one is able to refuse to co-operate in the search for accountability and justice ever again. There is so much in the stories of the families in Nottingham that is shocking and heartbreaking, but the way the bodies of their loved ones were handled by hospital mortuary services revealed a level of disrespect and a lack of humanity that—I will be honest—left me utterly aghast. The details are disturbing, but they need to be heard to understand the gravity of what families were confronted with: deceased babies referred to as a “specimen” or “sample”; a baby placed into a mortuary space already occupied by an unknown and unrelated adult; a baby disposed of as clinical waste against the express wishes of their parents; and a baby kept in a domestic fridge in a bereavement room. The emotional and psychological effect of those dehumanising failures was to layer the most profound disrespect on the most unbearable distress. There is also evidence that the trust actively decided not to report failings in mortuary care to families. As hon. Members will know, there is an active police investigation and arrests have been made, which limits what I can say. As a start, however, I have asked NHS England to write to trusts to make sure these appalling experiences are not happening elsewhere in the NHS. I confirm today that the Human Tissue Authority will require all mortuaries to review internal records going back 10 years to ensure all incidents have been logged and reported. I have instructed them to report the findings directly to me by 16 October. When I met the Nottingham families last week, they also raised with me the issue around what are known as secondary victims. In maternity settings, fathers, partners and others are actively encouraged to be present to support mothers through labour and delivery. However, the law does not allow them to bring their own claims for the psychiatric illness suffered as a direct result of witnessing their partner or baby suffer injury or die. I have therefore asked David Lock KC to work with my officials to consider that important issue as part of his wider work on clinical negligence. Donna Ockenden acknowledges that NUH has not waited for her findings to be published to start making improvements. I will speak to the chief executive next week to interrogate the trust’s response and make sure there is a proper plan in place for implementing the recommendations speedily and effectively. But there is a long road ahead before NUH fully addresses all the issues and before it can possibly regain the full trust and confidence of the communities it serves. I close where I began: with the families. Nothing can make up for what they have gone through, but this report is a tribute to their resilience and tenacity. I say to them directly: you had to drive this for so long, but you are no longer driving this alone. We are with you and we will not stop until you have the accountability and the justice you deserve. I commend this statement to the House.

I call the shadow Secretary of State.

I thank the Secretary of State for advance sight of his statement and Donna Ockenden and her team for the care and compassion with which they conducted the review. We had a meeting with her yesterday, and I have to say that it was probably one of the most difficult meetings that I have ever had. I pay tribute to the hon. Member for Sherwood Forest (Michelle Welsh). I can see how deeply personal and painful this is, and I admire her and all her colleagues from the region at what must be a very difficult moment. Let me say from the outset that I want to be constructive in opposition when it comes to this issue. We need to work together; we have to see improvements. I begin with the women, babies, fathers, partners and families whose lives sit behind the review’s findings. To them, we owe a profound apology for failing them when a family should feel safest, most supported and most able to trust the care around them. For too many, that trust was broken; women were not listened to, families were not believed and warning signs were missed. Some suffered the deepest lost, others were left physically unsafe and others psychologically scarred. No statement can repair that pain, but it can mark the point at which testimony becomes responsibility, and responsibility becomes action. The painful truth is not only that the failings occurred but that the themes are familiar: women not heard, families dismissed, poor communication, missed deterioration, weak governance and people unable to speak up. Maternity and neonatal safety has challenged Governments of both parties, but it would be wrong to let that history soften the urgency. Women and families are tired of telling their story, hearing promises and seeing the same themes return. The question is whether the system will move because of this review, and so I put three tests to the Secretary of State. The first is the listening test. Women and families were not consistently listened to. Their concerns were too often dismissed or not acted upon. That is not a soft issue; it is a safety issue. How will the Government embed listening as a clinical discipline? How will trusts measure whether women feel heard? Will complaints and near misses be treated as information for improvement? The second is the culture test. The review describes bullying, hierarchy and poor psychological safety affecting staff’s decisions and willingness to escalate. I pay tribute to those who were brave enough to do so. In maternity and neonatal care, minutes matter. If staff cannot challenge, safety is weakened. Staff cannot provide the care they want to if they are exhausted or unsupported, or if hierarchy matters more than candour. So I ask: how will boards be held accountable for that ward culture? The third test is the delivery test. Harm rarely followed one error; it usually followed a chain of poor communication, weak risk assessment, delayed escalation, staff pressure, inadequate governance and missed learning. The response cannot be a single announcement. It must be accompanied by a delivery plan, so will the Secretary of State publish a national implementation plan with named accountability, delivery dates and regular updates to this House? That plan must address the workforce so that staff have the support and information they need to fulfil their roles to the ability they wish. That plan must design services for today and the future, not rely on assumptions from the past. Women are having children older, pregnancies are more complex and more women are entering pregnancy with pre-existing conditions, previous loss, fertility treatment, mental health needs or circumstances shaping care. That means a need for practical, personalised care, informed choice and each woman being treated as a whole. The review also requires us to confront inequalities. The safety of a patient must not depend on confidence, class, ethnicity, language or an ability to fight through the system. The issue with our mortuaries is also really shocking. The horror stories that we have heard must never happen again. Is the Secretary of State working with colleagues in the Department of Justice to see what more needs to be done to overhaul this area? Finally, we must recognise the psychological harm caused through silence, poor communication, lack of bereavement support and the battle for honesty. We know that our mortuaries need to have the highest standards. Compassion after harm is not a courtesy; it is a duty. Trust is rebuilt when women feel the difference in the room, when words change decisions, when staff speak without fear, when risk is escalated in time and when boards are judged by results. Where the Government act to improve safety, accountability, staffing and family voice, they will have our support so that we can see this through together. Where they do not, they will face our scrutiny. This review began with families who had to fight to be heard. The task now is to ensure that no family has to fight so hard again.

I thank the shadow Secretary of State for not only the content but the tone of his response, and for the approach that he has taken. I firmly welcome this collaborative approach, because he rightly points out that this is an area that we should work across parties and across this whole House to address. His summary of the key issues that we must address through the work that we are doing—first and foremost, ensuring that women are listened to; the cultural changes we need to see; and the delivery test, recognising that this is a chain of failure—was very well made and in line with where I and the Department are coming at this issue from. As I mentioned earlier, all the recommendations from today’s report, as well as the recommendations from the national report that Baroness Amos has been working on and from other inquiries and reviews of maternity service failures, will come to the national taskforce that I chair, precisely to deliver that delivery plan—that comprehensive plan of action. We will ensure that it is published by the end of this year, and the Government, working with the Opposition, will ensure that it is delivered across this country.

I thank the Secretary of State for his statement. For openness and transparency, I note that I have been campaigning on this for six years and I am a harmed mother at Nottingham University hospitals NHS trust. I start by thanking the brave families—my friends—and Donna Ockenden and her team. What has happened is horrific: bullying, cover-ups, racism, discrimination and appalling practice. The way babies have been treated at birth and then at the end of their life is a national disgrace. One of the most uncomfortable truths in this report is that it was not a regulator, a policy, a protocol, a law or a Government Department that brought us this inquiry; it was families—bereaved families, harmed families—having to speak again and again about their most horrendous and traumatic experience for more than a decade. That does not signify a system that is working. The report identified avoidable deaths, harm and profound failings. The publication of this report is simply not enough. What is required now is action, accountability and change. Can the Secretary of State therefore assure the House that there will be a plan with robust oversight and questioning of regulators and senior staff? Will he work with Nottinghamshire families and Nottinghamshire MPs to ensure that justice is truly and fully delivered?

I thank my hon. Friend for her questions. Let me put on record again how much I have appreciated her advocacy, her support, her sharing of her own experience and her standing up for the many hundreds of families in the area she represents. Her contribution is invaluable to this most important work that we are doing as a Government. She talked about families driving this report and making sure that it happened, and she is absolutely right. I met some of those families last week in Nottingham, and as well as feeling numb at the depth and breadth of their pain, the feeling I left with was a sense of their exhaustion at having fought for so long to be listened to and to get this into the open. Our responsibility as a Government and as MPs is to say that, now it is out in the open for us all to see, we all bear a responsibility to help them carry this forward. I take that responsibility with the utmost seriousness. My hon. Friend asked about a plan to change maternity services in Nottingham and across the country. There will be specific local recommendations in Nottingham, and I am meeting the chief executive of the trust next week to pick that up directly with him, but there are more recommendations in the report that will have national implications, along with the recommendations from the national review that is under way. It is crucial that all those recommendations are formed into a plan of action, and the taskforce that I chair will be crucial in making sure that these recommendations do not just get accepted and then sit on a shelf gathering dust, but form a plan of action that we can stand behind as a Government. Finally, my hon. Friend mentioned the importance of action, accountability and change. I repeat what I said in my statement: one of the phrases that stuck with me powerfully from my meeting with Nottingham families last week was from the person who said that “accountability drives action”. Without that accountability, we cannot have a guarantee of action. That is why the accountability that the families seek is the change that we as a Government must seek to deliver.

I call the Liberal Democrat spokesperson.

May I start by acknowledging the hon. Member for Sherwood Forest (Michelle Welsh), Donna Ockenden and the Secretary of State for the statement and for their hard work? I thank the Secretary of State for the actions that he has proposed so far, which I think are the first tangible actions we have heard in this place. I must also acknowledge the incredible courage and resilience of the Nottingham families who have been instrumental in bringing about this review. No one can imagine the pain that they have gone through. I am distressed and angry to be stood here once again speaking about babies who should not have lost their lives, mothers who should not have lost their lives and trauma that families should not have experienced. Review after review has led to 748 recommendations since 2015, but birth injury and mortality rates have continued to rise. These reviews all reveal similar issues: unsafe staffing levels, lessons not learned, issues not escalated, insufficient training, and women’s concerns ignored. Four years ago, after the Shrewsbury review, we found that over 200 babies had died unnecessarily in Shropshire, yet things have got worse. Donna Ockenden’s Nottingham report reveals new and extremely distressing revelations about serious failures to protect the dignity of the deceased in after-death care, something that must be addressed through proper regulation. Liberal Democrats have put forward a maternity rescue package that would guarantee one-to-one midwifery care and introduce a national maternity commissioner to oversee vital improvements. It would be nonsensical for the Government not to take a strategy forward. Will the Secretary of State pledge to implement every single one of the Nottingham report’s essential actions, and to work with us to deliver the essential investment we need to make Britain a safe place to have a baby, and end this shocking cycle of failure? Anger is not enough. Mothers, doctors and midwives are sick of seeing review after review and being met with stasis, with the same failures repeated over and over again. This must be the moment we say, “Enough.”

I thank the hon. Lady for her words. When she spoke about ending this cycle, she sums up a feeling that I think many of us have: the cycle of inquiries and investigations revealing what has been happening in maternity services and leading to recommendations, which are accepted, but then things do not change enough, and action is not taken to address all the issues raised. That is the cycle we need to break. The national taskforce, which is established and which I chair, will take all the recommendations from Donna Ockenden’s report, as well as those from Baroness Amos’s national review, which will be published shortly, as well as some of the other hundreds of recommendations that the hon. Lady mentioned, and ensure that it produces a comprehensive action plan by the end of the year. The challenge for us is not simply to accept recommendations, but to produce and deliver that action plan.

Today’s publication of Donna Ockenden’s report into maternity services in Nottinghamshire is a difficult and deeply emotional moment for families across our county and city. I want to place on the record my thanks to Donna Ockenden and her outstanding team for the care, compassion and thoroughness with which they have exposed the devastating cases of these families. Let me also place on the record my thanks to my hon. Friend the Member for Sherwood Forest (Michelle Welsh). She is a fearless and formidable campaigner for justice and has walked this journey with the families every step of the way, and I know just how proud her son Billy will be watching her from home today. My thoughts are first and foremost with the families whose lives have been changed forever by the loss of their babies, and the mothers who should have received safe care but were harmed. Behind every page of this report are families who have endured unimaginable grief and who have spent years fighting simply to have their voices heard. I pay tribute to their courage, dignity and determination. In the face of heartbreak, they refused to be silenced. They fought not only for answers about their loved ones, but to ensure that other families would not suffer the same pain. Can my right hon. Friend confirm that he will consider all options available to deliver justice and accountability for those families who have waited far too long for answers? Will he assure me and the whole House that the lessons identified in the report will be fully implemented and embedded throughout maternity services in Nottinghamshire and around the United Kingdom, so that no family has to endure what far too many families have already endured?

I thank my hon. Friend for his comments and questions, and I echo his words about paying tribute to the courage, dignity and determination of the families who have driven the report and driven these shocking failures out into the open, so that we can all see the scale and depth of what has happened. He asks me about embedding the lessons from the review. I assure him that my priority is to ensure that the local lessons around the situation in Nottingham are embedded, and I will meet the chief executive of the trust next week, but also that those recommendations that have implications about national maternity services are taken directly into the taskforce that I chair, along with recommendations from other reports, and that we produce that plan of action by the end of the year. Let me also reassure him that, in that search for change, justice and accountability, I will take nothing off the table.

I call the Chair of the Health and Social Care Committee.

I, too, pay tribute to those families who came forward with their stories, but also to the thousands, if not tens of thousands, of families across the country who are hearing these stories today and are triggered because it reminds them of their own, including in my area in Oxfordshire. What struck me most about the report was the section on leadership and culture, and how when midwives and members of staff raised the alarm, they did not have access to the board, and board members were not curious enough to ask the right questions. I am also struck that in the Secretary of State’s answers—he is right to point to the national recommendations that are yet to come; our understanding is they are coming next week—he failed to mention whether there will be any pot of money to ensure that any recommendations that need double-running in order to happen quickly will have the necessary resources. Can he assure the House not only that will his taskforce seek to implement these recommendations, but that he will ensure that the money exists for staffing, training and buildings so that they are implemented as quickly as possible, so that we do not have to sit here crying on these Benches on behalf of our constituents any more?

I thank the hon. Lady for her comments. She speaks about funding, which is of course a very important part of the response that we need to have to the failings in maternity care. We are investing £25 million, as I am sure she is aware, in tackling the causes of maternal death, to enhance bereavement facilities and to improve triage facilities, as well as £145 million through the estates safety fund to address safety risks in the maternity and neonatal estate. For me, this is not just about funding; this is also about culture, exactly as she says. When there is a culture of mothers and midwives not being listened to, and of the board, in this case, commissioning reviews and then ignoring them, that is where the problem lies. That is what we need to change. There is no single lever we can pull, no single change we need to make; we need to ensure that, from top to bottom, maternity services are overhauled in order to be fit for the future.

First, I want to thank the families who were bereaved and harmed by Nottingham University hospitals NHS trust—some of the most courageous and selfless people I have had the privilege of knowing, including my hon. Friend the Member for Sherwood Forest (Michelle Welsh). They have for years relentlessly pursued the truth, justice, accountability and real change, often at great personal cost, and not only for their own families but to prevent future families having to endure similar trauma and cruelty. I also want to express my sincere gratitude to Donna Ockenden for her service to Nottinghamshire. I am so thankful that it was her who led this review. The scale and magnitude of the systemic failures uncovered by the review are truly harrowing. Mothers and babies were harmed and even died through the most shocking negligence and indifference. Families were lied to, disbelieved, blamed and gaslit. Mistakes were covered up and regulators failed to do their jobs. One of my constituents included in the review summed up well where we go from here when she told the Secretary of State that “we need immediate action and we need long-term accountability”. On immediate actions, will the Secretary of State set out a timeline of when he expects to be able to implement the recommendations in full? On accountability, is he open to a statutory inquiry, provided that it does not delay criminal proceedings?

I thank my hon. Friend for her comments and questions. As well as thanking the families for what they have done to drive the report forward, she also thanked Donna Ockenden for her critical work in producing this report, and to those thanks I add my own. My hon. Friend asks about the timetable for action. The national taskforce, which I chair, will draw together all the national recommendations, all the recommendations from Donna Ockenden’s report, the recommendations from Baroness Amos’s report, and any other report on failures in maternity services, and the taskforce will report by the end of the year. That will be the timetable for us ensuring that there is a comprehensive plan of action. I know from my conversations with families that some have wanted a public inquiry and others have had different views. Let me be clear that, for me, no options are off the table.

It is a matter of profound shame for all of us in the House that in a society that we call compassionate, a baby’s body could be disposed of as clinical waste. I add my thanks to the families and salute their courage, including the hon. Member for Sherwood Forest (Michelle Welsh), and particularly Jack and Sarah Hawkins, and all those families who have shown such courage in coming forward with these utterly appalling stories. I commissioned a number of maternity reviews, and I am afraid that today I feel a terrible sense of déjà-vu. I worry that a lot of the recommendations, and the things that I suspect the Government will end up doing, amount to central direction and central control, which we know usually does not work in the NHS. I was encouraged that the Secretary of State, in his thoughtful comments, used the word “accountability”, because the core problem is a lack of clinical accountability. For his solutions, will he consider a complete overhaul, so that every mother, the moment she knows she is pregnant, is given a small team, including a doctor and midwives, and is told, “This is the team, this is the person who is responsible for the safe birth of your child”, so that she always knows who to go to? That is where things are currently falling between the seams. Ensuring that people always know who is responsible and who to go to is the only way that we will stop these things happening time after time.

I sincerely thank the right hon. Gentleman for his comments. I have a great deal of respect for him, as he knows, so I very much appreciate him making his suggestions in that manner. Let me add to what he said about Jack and Sarah Hawkins, who I met last week in Nottingham. Their sheer determination to push for accountability and justice is incredibly humbling. The right hon. Gentleman mentions the importance of clinical accountability, which gets to the core of how to drive change in the NHS—as he knows, and as I now know, that is not always possible through central control, or by instructions being sent out from the Department of Health and Social Care or NHS England. We must ensure that the entire system is structured in the right way to provide that accountability and to drive change and action, and I will put under careful consideration his suggestion about how that might be achieved.

Today’s publication of Donna Ockenden’s report has laid bare absolutely appalling and systemic failures in maternity services in Nottinghamshire, with thousands of families suffering avoidable harm, and in many cases feeling ignored, dismissed or let down by the very institutions that were put in place to protect them. The report identifies profound failures of leadership, governance and accountability, and an inability to learn from mistakes. Given the scale of the failings and the repeated concerns raised in previous maternity reviews, is it now time for the Government to establish a full, judge-led, statutory public inquiry, with the power to compel witnesses, and examine whether wider NHS and regulatory failures have allowed these tragedies to occur over such a prolonged period?

My hon. Friend raises the important issue of compelling witnesses to give evidence. Although many members of staff contributed towards Donna Ockenden’s review, I found the fact that so many senior leaders did not shocking, and I think it is unacceptable. We will change that by ensuring that the duty of candour, which is due to come in under the Hillsborough law once that is in place, will apply to future maternity reviews, including those taking place in Leeds and Sussex. As I said a few moments ago, there are different views among different families about whether they do or do not want a public inquiry, but I am not taking any options off the table.