National Maternity and Neonatal Investigation

My Lords, I thank the Minister for the Statement and the noble Baroness, Lady Amos, and her team for the thoroughness and compassion with which they have conducted this important investigation. Above all, our thoughts must be and are with the women, babies and families whose experiences lie at the heart of this report. Many have had to revisit the most painful moments of their lives when some want to simply move on. But after years of fighting, they must be heard. Their courage, dignity, determination and persistence place a responsibility on all of us in this House. We owe it to them not simply to listen, but to ensure that their experiences finally lead to lasting change. Only last week the House considered Donna Ockenden’s devastating findings in Nottingham. Here, the noble Baroness, Lady Amos, presents us with a wider national picture. Once again, we see the same troubling themes emerge—women whose concerns were dismissed, staff who felt unable to speak up, inequalities that remained unchallenged, and organisations that failed to learn from previous mistakes. As Donna Ockenden herself observed, much of what is contained in this report is sadly already known to us, as it was to Governments of all political colours in previous years. That is perhaps the most disturbing and sobering conclusion of all. The challenge before us is no longer one of evidence. We have had inquiry after inquiry, report after report and recommendation after recommendation. The challenge now is implementation. Families have every right to expect that this report will become the catalyst for sustained improvement across maternity and neonatal services. I am sure that all noble Lords welcome the fact that work is beginning immediately in a number of critical areas, including maternity triage, tackling discrimination, strengthening staffing and addressing urgent estate risks. It is right that today’s expectant mothers be given assurance and reassurance about what will change immediately, not only at the end of the year when the wider plan is due. A few outstanding questions arise from the Statement. First, can the Minister update the House on the timetable for the Leeds and Sussex reviews? How will the Government ensure that concerns which have already been identified in those services are acted on before these reviews conclude? Secondly, it is welcome that the Secretary of State will publish the new maternity triage standards next week, but by when does the Minister expect every NHS trust to have implemented these standards and will Parliament receive regular updates on trust-by-trust progress so that families can see that improvements are generally being delivered? Thirdly, the Government propose establishing a statutory maternity and neonatal commissioner. Can the Minister explain what powers the commissioner will have to hold trusts, regulators and national bodies to account? How will local leaders remain accountable for the safety of the services that they are supposed to oversee? The additional midwifery posts announced today are also welcome, but the report from the noble Baroness, Lady Amos, like those before it, identifies workforce pressures as a fundamental challenge to safe maternity care. Do the Government intend to address this issue immediately, or will we have to wait for the long-awaited workforce plan? If it is the latter, can the Minister update the House on when it will be published and whether it will specifically address maternity and neonatal services? I can understand her perhaps raising an eyebrow here, as she rightly and persistently challenged me on this when I was a Minister in her place. Since the report’s publication, concerns have been raised by Dr Bill Kirkup about the removal of references to so-called normal birth ideology from the final report. Previous maternity inquiries have identified this as a contributory factor. It would not be fair of me to ask for comment on the editorial process, but can the Minister reassure the House that all relevant evidence—including from Morecambe Bay, which found that midwives were pursuing normal birth at any cost—will be fully considered? Finally, the Secretary of State is right that culture lies at the heart of this challenge. Often, while policy changes and restructures are visible, it can be more difficult to bring about cultural change. Where the Government act with the urgency that this report demands, they will have our support. However, women and families will judge today’s Statement not by new structures, new titles or another report, but by what happens when a woman says that something is wrong. Is she heard? Are warning signs acted on? Is help from senior colleagues available when needed? Are maternity units safely staffed and can staff speak up without fear? Do families receive honesty and compassion when harm occurs? Above all, are we reducing the number of mothers and babies coming to harm? Families have told their stories. The evidence is clear. We will support and, where appropriate, challenge the Government and the NHS as they seek to bring about this much-needed change. The Minister in the other place has made a good start, and we hope to see further progress.

My Lords, this is another week and another traumatic and difficult-to-read report about the state of maternity services. Behind it are thousands and thousands of women and families deeply affected by these service failures. I thank them all for their contributions to this report, as well as the noble Baroness, Lady Amos. Women are not being listened to, heard or believed, with serious consequences for safety and quality of care. Racism and discrimination are embedded throughout the maternity and neonatal system. Services are not responsive to the changing profile of women giving birth and the increase in medical interventions during birth. Antenatal, birth and labour, neonatal and postnatal services are just not joined up. From Somerset to Blackpool, the safety of having a baby has become a lottery. Women are silenced and staff who raise the alarm on unsafe care or systemic discrimination are crushed by a culture of fear. We need to see genuine accountability throughout the NHS and the investment necessary to make Britain the safest country in the world to have a baby. I have a number of questions for the Minister. I welcome the Government’s commitment to a national maternity commissioner, but can the Minister confirm that this post will go to an independent expert and not a political appointee? Will the Minister reassure us that action will be taken before December, rather than waiting for the taskforce to report on its plans? Will the Government guarantee safe staffing at all hours in every maternity ward in the country, so that no woman has to give birth in an unsafe unit? This inquiry has, once again, raised the issue of poor bereavement support across the NHS after pregnancy or baby loss. The national bereavement care pathway seeks to resolve this by ensuring high-quality and consistent bereavement care across the UK. The trauma of baby death and pregnancy loss can last a lifetime. Parents’ memories of the care they receive at that moment will stay with them for ever. Good bereavement care can help parents and families navigate their bereavement journey, while poor care can just add to the trauma of loss. The first moments after a baby dies can be the only opportunity parents have to make memories with their baby, and there is only once chance to get this right. After a baby dies, parents often face really tough decisions, and they cannot make informed decisions about their baby without clear and compassionate communication from healthcare professionals. I therefore ask: will the Government roll out all five national bereavement care pathways, including for miscarriage, and actively monitor implementation across the health system? Will they ensure that suitable bereavement rooms are available in all trusts, not as a “nice to have” but as part of dignified trauma-informed care? This would be a step change for so many families. There is so much more I could say on a topic that has shocked us all. All families, wherever they live and whatever their ethnicity, must be supported to have their babies safely. This has clearly not been the case for too many years. This is the point where things must change, and I really look forward to the Minister’s response.

My Lords, we know—and we can never acknowledge it enough—that women, babies and families across the country are being harmed, traumatised and let down by a broken system. I am grateful to both Front Benches for the way in which they have received this report and for their support, and their acknowledgement of the role we have taken in government. The noble Baroness, Lady Pidgeon, talked about trauma lasting a lifetime, and that is indeed the case. When I have met women and families who have been affected, that is what has stuck with me: the trauma never goes away. I also accept the correct challenge from the noble Lord, Lord Kamall, that the judgment will be on what has changed, not on what is written. We are very conscious of that, and I am grateful to him for reminding me of it. Before turning to the helpful questions from the noble Baroness and the noble Lord, I will make a few comments. I too want to express my gratitude to every woman, family member and member of staff who came forward to give evidence to the noble Baroness, Lady Amos, and her team, who heard from thousands of people who showed great courage and determination to share their experiences, painful though they were, and conducted their investigation with immense sensitivity and care. The noble Baroness, Lady Amos, diligently brought together evidence from families, staff, 12 local investigations and all the past reviews, and her review shows systemic, repeated failures by our maternity and neonatal system. It has also given us the opportunity and determination to break that cycle. As I know your Lordships’ House will agree, it is also important that we acknowledge the very positive role that so many staff and families have played in providing the necessary care. It was most helpful that some of our immediate actions were acknowledged. But, on top of those immediate actions, some of which have been mentioned today, we have ongoing actions. We have been tackling avoidable brain injuries and maternal deaths through dedicated programmes and packages. We have already begun the expansion of Martha’s rule to all maternity and neonatal units, to give families and patients the right to request a second opinion where there are concerns. Among other things, we have also introduced a perinatal culture and leadership programme, which is important to develop a safety culture and a learning and support culture for the leadership across all units, and an early warning system to better identify safety concerns. Importantly, because continuity of care is something that has been highlighted a lot, we are providing £10 million of recurrent funding to ICBs for this very purpose, in particular to provide midwifery continuity of care for those women who live in the most deprived neighbourhoods and who are at risk of poor outcomes. I will do my best to answer the questions asked by noble Lords. The noble Lord, Lord Kamall, asked about the timeline for Leeds and Sussex. Donna Ockenden, who will be chairing those reviews, is currently engaging with the families on terms of reference, which will include timelines. We will not be waiting for the publication of the findings to make changes. As they emerge, those issues will be shared with us, so that we can act. In answer to the question from the noble Lord, Lord Kamall, the new maternity triage standards will be implemented by June 2027. There must be clear board oversight in place of the operation of the triage system, including regular reviews of waiting times and actions to improve the necessary services. The role and remit of the maternity commission is being urgently considered by the National Maternity and Neonatal Taskforce. The commissioner will co-chair the taskforce, which will drive all the change as well as setting it out. On workforce pressures, we are not waiting. There is £10.6 million investment funding in an additional 1,000 temporary roles to help newly qualified midwives to join the NHS, which is extremely important. So, we are not waiting for the 10-year workforce plan. However, the taskforce will take into consideration wider work, including the 10-year workforce plan. With regard to concerns raised by Bill Kirkup about what is referred to as “normal birth ideology”, women have to be able to make the right decision about what is safest and best for them. No woman should ever feel pushed into a particular type of care. The words “normal” and “natural” are perhaps not particularly helpful in this setting. We are talking about vaginal births; what matters is what is best and what is safest, and I am certainly very grateful to Bill Kirkup for all this work. The noble Baroness, Lady Pidgeon, asked further questions about the commissioner, which were helpful. The selection and appointment process will be considered as part of the process of establishing the role. Questions were asked on action being taken before December, when the report of the taskforce will be available. As I mentioned, immediate actions are already being driven forward. These actions were already under way over the last two years and as part of the immediate response to the recommendations of the noble Baroness, Lady Amos. Where we can, we have already actioned work, and, where we need further work done, that will be developed over the next few months, at pace. The noble Baroness raised a good point about the rollout of bereavement pathways, including for miscarriage. We are rolling out all five strands of the national bereavement care pathway. All trusts in England have signed up to implement the core standards of the national bereavement care pathway. That is relevant in this case and, across other areas of bereavement, is of particular concern. As I draw my remarks in this section to a close, let me give noble Lords a sense of the urgency. The taskforce and its supporting expert reference groups are meeting tomorrow to discuss the findings of both the Donna Ockenden report, on which we had a Statement last week, and the report by the noble Baroness, Lady Amos. Next Tuesday, the taskforce—which is spearheading all this and chaired personally by the Secretary of State—will be meeting to discuss next steps for the action plan. To the questions from the noble Baroness, Lady Pidgeon, about the commissioner’s role, the Secretary of State has already said that he wishes that the maternity and neonatal commissioner will co-chair the taskforce with him. That would be a very welcome move. I hope that I have dealt with the questions and, more than that, given a sense of the pace and seriousness, as well as the action that I know we all seek.

My Lords, I declare an interest as the chair of the Royal College of Obstetricians and Gynaecologists board of trustees. The RCOG desperately wants to see an improvement in the services that mothers and children are getting in maternity. I do not know whether the Minister is aware that some 68% of all clinicians are working hours way beyond their contracts, and 25% of them are talking about leaving the profession within five years because of a fear of burnout. Obviously, everything must be done to prevent that happening. Does the Minister agree that workforce planning is central here, including better integration between the work of doctors in maternity and midwives? There should not be barriers between the two; they should be working in units together and dealing with high-risk cases. In that context, will some decision be made pretty soon about when a redesigned workforce tool will be available for obstetricians in particular? They desperately want to see that as soon as possible and do not want to have to wait maybe as long as a year before an action plan is completed.

My noble friend allows me to say how grateful we are to the Royal College of Obstetricians and Gynaecologists for its continuing work, as we are grateful to our many partners who are committed to driving through change. We are working particularly closely with RCOG in developing routes forward. I agree with the points that my noble friend made. Most NHS maternity staff—and other staff, but we are talking about maternity staff—are providing exceptional care. It must be very difficult for them to hear about and read these findings. Our job is to support them with the right culture and leadership, and to equip them and support them to listen and learn. It is important that we have the right skills mix among consultants, to whom my noble friend refers, and retain them, because they are absolutely key. We will continue to work with RCOG accordingly.

My Lords, like others I recognise the kindness and compassion that the majority of staff in our health service deliver, but as the Secretary of State for Health and Social Care rightly said: “We must break the cycle of recommendations sitting on a shelf gathering dust”. The Minister has already made it clear that the reviews currently planned will continue. I wondered whether they might be postponed or cancelled, but, as they are not going to be, will we ensure that we stop looking further and actually implement what is necessary now, in particular more senior midwives on duty at night? As well as employing more midwives, can we look, through the NHS workforce plan, at putting both general nurses and mental health nurses on fast-track midwifery courses so that we have experts in other areas working in midwifery?

I know that the noble Baroness, Lady Amos, made the kind of comments to which the noble Baroness refers. The National Maternity and Neonatal Taskforce will certainly look at all these areas and, as I mentioned, those reviews will continue. I emphasise that we have to bring this cycle to a close. That is exactly why the former Secretary of State commissioned the noble Baroness, Lady Amos, so that we would bring together a coherent, fully informed list of national recommendations. That is indeed what we have, and we have already actioned a number of them. To the points that the noble Baroness made, that work will continue and will not be held up.

My Lords, I will follow on from the excellent question and suggestions from the noble Baroness, Lady Watkins, about specialist nurses being fast-tracked into midwifery. Donna Ockenden’s report found that many student and newly qualified midwives feel they do not have the necessary level of skills to deal with complex cases. What conversations will the taskforce or the commissioner have with the Royal College of Midwives about the training pathway for midwives? Currently, the Royal College of Midwives does not seem to see any need for a return to nurse training.

I am fully aware of—I will put it tactfully—the difference of opinion in this regard. This morning, I was speaking with one of our main advisers, who did not feel it was necessarily an answer to go down the road of midwives being nurses—I know the noble Baroness did not say that—and I bow to that experience, but for me it raises the complexity. It is important to emphasise a point about which I have been concerned for some time: about a third of student midwives have no role to go to. The noble Baroness is right, but some of it is about basic experience, and nobody can gain experience without putting the years in—that is a fact. That is why getting the new funding, up to £10,000 per post, means we will keep students in the profession and give them the chance to develop the very important expertise to which the noble Baroness refers. Further, having multidisciplinary teams and the right people means that you can manage whatever complexity. There is no way that any one person can deal with all complex cases. Every case has a high degree of individuality, as I know the noble Baroness is aware.

My Lords, “welcome” is not quite the right term to use about these reports, but they are indeed absolutely essential. I need to declare that I am the maternity lead, as a non-executive member, at the Whittington Hospital, and I will be at the conference as a member of one of the reference groups tomorrow. Several years ago, when Donna Ockenden produced her first reports, we set up what we called the Ockenden cafes in the Whittington, to which we invited all the multidisciplinary teams, plus mums and patients and people who had been involved over a period of time; it was an enormously valuable and uplifting experience for all of us involved in the maternity care of the women in our area. However, I want to ask my noble friend about MIS, the Maternity Incentive Scheme, which is now in its eighth year and, as she will know, is designed to get maternity units to improve year by year and through that win some investment in their hospitals. Has that been factored into what might happen next?

I thank my noble friend and all her colleagues for the work they do. We have many examples across the country of first-rate care and great initiatives like the one my noble friend spoke of, which really takes on board one of the problems the noble Baroness, Lady Amos, found: that the voices of women and their families, and of staff, were just not heard or acted on. That is the one thing that comes through. To the question, would the abbreviation be MIS in this case?

Yes, MIS.

We have two “MISs” that we often talk about: MHIS and MIS. I will ensure that MIS is considered, but it is probably worth saying that we are already developing a tool for assessing the quality and experiences of care being provided for women using maternity services, through the patient reported experience measure. To the point made earlier by the noble Lord, Lord Kamall, that is one of the ways we will ensure that women and their families can actually see, feel and know the difference.

My Lords, I draw noble Lords’ attention to my registered interest as chairman of King’s Health Partners. In addition to addressing workforce concerns and driving a much-improved culture in the delivery of maternity services, the physical environment in which maternity services are delivered is critically important. These are very frequently delivered in some of the worst parts of the NHS estate in such a way that the holistic nature of the services that need to be provided is not available at a single site. Can the Minister confirm that the NHS capital budget identified for this spending period is going to be protected so that these matters might be addressed?

The noble Lord makes a very accurate observation. Perhaps I can go a bit further than he is asking me, because just last week we announced an additional £41 million of safety funding to improve the estate. That is on top of the £145 million that was previously announced, so that will give a great opportunity to really improve the estate, which is crucial for safety as well as experience.

My Lords, my sister died at birth, so I remember well the impact this has on families. What more can the Government and the NHS do to help those families who have lost a baby in such painful circumstances, or who are now bringing up a disabled child as a result of medical difficulty?

I am very sorry to hear of the loss the noble Lord experienced and of the deep effect on his family; I am sure he still lives with that feeling. I think the greatest gift we can give is to reduce the risk of something going in the way that it did in his family, and that we avoid all avoidable risks. That is exactly what this work is about, and that would be the right thing. For those who are affected, I mentioned the bereavement pathways. In terms of support that ICBs arrange across the country, there is a much greater awareness of the need to support people when they need it most.

My Lords, both the report of the noble Baroness, Lady Amos, and the Ockenden inquiry identified poor leadership cultures—defensive cultures, dismissive cultures and doctor-knows-best cultures. The noble Baroness already referred to the voices of women and their partners being ignored, particularly when they are complaining of pain. Is the Minister satisfied that the various important recommendations, provided they are implemented and seen through, will fundamentally address and change this culture?

It is a challenge to take on a deep-rooted culture, but we are doing that and it will require action at every level, without doubt. The main thing, as the noble Baroness said, is putting women, babies and their families at the heart of care. This has not been the case. NHS England’s chief executive brought all trust chief executives to London on the day the report was published to discuss the urgent actions trusts can take on this and to focus on the next 100 days. All perinatal leadership teams have also completed a culture and leadership programme, which I believe will strengthen collaboration across maternity and neonatal services. Those are just two of the actions we will take, but this is absolutely fundamental to all the system changes.

My Lords, I listened to this short debate with a bit of amazement. We are looking at the end results, but we need to look a little further up the channel. My noble friend Lady Blackstone touched on a very important point, as indeed did the noble Baroness, Lady Pidgeon, which is much more crucial than we may perhaps understand. First, as has been said, these people come to hospital not to access maternity services but to have a baby. They are not ill. That is different from the rest of the NHS, even though they are in the NHS. What we are partly seeing here is a cultural situation that is a problem throughout the NHS, not just in maternity services. It is bad in maternity services for the obvious reason that, in the main, these people are healthy, although some are not terribly fit. We are losing the plot a bit. For example, the noble Baroness, Lady Pidgeon, said that there is a need for much better psychological support, and I agree. We tend to forget that a woman who is having a baby, even a normal baby who is fully alive, is losing a life within her uterus. She feels a loss when that happens. It may not be expressed as a loss—it is expressed as happiness—but it is an extraordinary change of feeling, which psychiatrists know is very common in maternity. We forget that this affects not just women but men as well. We also sometimes assume, as we have done in this report—certain things are obvious—that it is much better not to have a caesarean section. That has been suggested, but it turns out that a caesarean section is safer than a vaginal delivery, if you want to be absolutely safe. This has been shown through various studies. I am not advocating caesarean section, of course, but I am pointing out that we sometimes deplore it when it may actually be a useful thing to do. We have to understand that we are looking at not a broken service but a service under great stress, and we have to deal with that. The noble Baroness, Lady Blackstone, pointed out that its manning is very inadequate. It needs to be a consultant-led service and people have to stay in overnight, but there is not always enough conversation between midwives and obstetricians. There needs to be much closer understanding between the two. Above all, the culture should be one of kindness. Kindness is what we must ensure.

I absolutely agree with what my noble friend said about kindness; when we had the Statement last week, we discussed compassion as well. It is disappointing to have to talk about it, because it should be a given, but we have found that it is not. I totally agree that pregnancy is not an illness—I was once quoted as very sharply telling an interviewer that. I am not aware that it is, and it is not, but it is worth restating, in my view. On the role of men, I am very careful to speak about women and families; that is the right thing. I also clarify that, in this Statement, I do not believe anybody is suggesting that one form of birth is preferable to another. I think we would probably all agree that it is about the form that is safest and the right one for the circumstance.

My Lords, I thank the Minister for the Statement today and the noble Baroness, Lady Amos, for her excellent report. We have many reports now describing the tragedies occurring in maternity services. I hope this report will be the final one before we go back to delivering the best maternity care, as we used to. It was world leading. I am privileged to have been an obstetrician for nearly 40 years of my life, delivering many thousands of babies—normally, as people refer to it, and by caesarean sections, which are done when there is an indication to do so. We expect the mothers to enjoy normal deliveries, but also to enjoy the delivery when they must have a caesarean section. The greatest privilege I had was to hand a baby to a mother and see the first look on the mother’s face, which is unbelievable; I had the privilege to witness that first-hand, long before partners would see it. It is important that we deliver world-class maternity services and, therefore, that what the task force comes up with has the standards to be delivered. I hope it will be mandatory for those standards to be followed, monitored and audited against. It should be possible, at the mother’s first visit to the antenatal clinic, to have a plan for how her pregnancy will be managed by midwives and obstetricians. It should also be possible to have every maternity unit audited, as used to happen, when things go wrong involving the mother and the families—and to have a plan for how that will be tackled. I hope that will be the answer.

I am sure we were all touched to hear what the noble Lord said. It must be a privilege to have done what he has done, and to have affected so many lives—those at their beginning but also the lives of the women themselves and their families. I am sure we are all grateful to him for that. The work of the task force, and of the expert reference groups—I am so grateful to the noble Lord, as well as my noble friend Lady Thornton, for taking part in one of them—will be to develop a plan of action, not just for how it will happen but for how it will be audited. Perhaps I should say that key to all this is accountability. The Secretary of State himself said in the Statement that what stuck with him from one of the bereaved mothers he spoke to was that accountability is what drives change. Certainly, when it comes to the regulators, that is why we are also taking action to improve.