PARLIAMENTARY DEBATE
Ockenden Report - 30 March 2022 (Commons/Commons Chamber)

With permission, Mr Speaker, I would like to make a statement on the Ockenden report. The independent review was set up in 2017 in response to concerns from bereaved families about maternity care at Shrewsbury and Telford Hospital NHS Trust. Its original scope was to cover the cases of 23 families, but since it began, sadly, many more families have reported concerns. Due to this tragically high number of cases and the importance of this work to patient safety, early conclusions were published in an initial report in December 2020. We accepted all the recommendations of the first report, and the NHS is now taking them forward.

Today, the second and final report has been published. This is the one of the largest inquiries relating to a single service in the history of the NHS. It looks at the experiences of almost 1,500 families from 2000 to 2019. I would like to update the House on the findings of the report, and will then turn to the actions that we are taking as a result of it.

The report paints a tragic and harrowing picture of repeated failures in care over two decades, which led to unimaginable trauma for so many people. For these families, their experience of maternity care, rather than being of moments of joy and happiness, was one of tragedy and distress. The effects of these failures were felt across families, communities and generations. The cases in the report are stark and deeply upsetting. In 12 cases where a mother died, the report concludes that in three quarters of them, the care could have been “significantly improved”. It also examined 44 cases of HIE—hypoxic ischaemic encephalopathy—a brain injury caused by oxygen deprivation. Two thirds of the cases featured “significant and major concerns” about the care provided to the mother. The reports also states that of almost 500 cases of stillbirth, one in four was found to give rise to major concerns about maternity care that, if managed appropriately, “might or would” have resulted in a different outcome.

When I met Donna Ockenden last week, she told me about basic oversights at every level of patient care, including in one case where important clinical information was kept on Post-it notes, which were swept into the bin by cleaners, with tragic consequences for a newborn baby and her family. In addition, there were repeated cases where the trust failed to undertake serious incident investigations; and where investigations did take place, they did not follow the standards that would have been expected.

Those persistent failings continued until as late as 2019, and multiple opportunities to address them were ignored, including by the trust board accountable for these services. Reviews from external bodies failed to identify the substandard care that was taking place, and some of the findings gave false reassurances about maternity services at the trust. The Care Quality Commission rated maternity services inadequate for safety only in 2018, which is unacceptable given the huge deficiencies in care that are outlined in the report.

The report also highlights serious issues with the culture in the trust. For instance, two thirds of staff who were surveyed reported that they had witnessed cases of bullying, and some staff members withdrew their co-operation on the report within weeks of publication. The first report has already concluded that

“there was a culture within the Trust to keep Caesarean rates low because this was perceived as the essence of good maternity care”.

Today’s report adds:

“many women thought any deviation from normality meant a Caesarean section was needed and this was then denied to them by the Trust”.

It is right that both the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives have said recently that they regret their campaign for so-called normal births. It is vital, across maternity services, that we focus on safe and personalised care, in which the voice of the mother is heard throughout.

The report shows a systemic failure to listen to the families affected, many of whom had been doggedly and persistently raising issues over several years. One mother said that she felt like a

“lone voice in the wind”.

Bereaved families told the report that they were treated in a way that lacked sensitivity and empathy. Appallingly, in some cases, the trust blamed the mothers for the trauma that they had been through. In the words of Donna Ockenden, the trust

“failed to investigate, failed to learn and failed to improve”.

We entrust the NHS with our care, often when we are at our most vulnerable. In return, we expect the highest standards. I have seen in my family the brilliant care that NHS maternity services can offer, but when those standards are not met, we must act firmly, and the failures of care and compassion set out in the report have absolutely no place in the NHS.

To all the families who have suffered so greatly: I am sorry. The report clearly shows that you were failed by a service that was there to help you and your loved ones to bring life into this world. We will make the changes that the report says are needed, at both a local and national level.

I know that hon. Members and the families who have suffered would want reassurances that the individuals who are responsible for these serious and repeated failures will be held to account. I am sure that the House will understand that it is not appropriate for me to name individuals at this stage. However, I reassure hon. Members that a number of people who were working at the trust at the time of the incidents have been suspended or struck off from their professional register, and members of senior management have been removed from their posts. There is also an active police investigation, Operation Lincoln, which is looking at around 600 cases. Given that this is a live investigation, I am sure that hon. Members will recognise that I am not able to comment further on that.

Today’s report recognises that since the initial report was published in 2020, we have taken important steps to improve maternity care. That includes providing £95 million for maternity services across England to boost the maternity workforce and to fund programmes for training, development and leadership. The second report makes a series of further recommendations. It contains 66 for the local trust, 15 for the wider NHS and three for me as Secretary of State. The local trust, NHS England and the Department of Health and Social Care will accept all 84 recommendations.

Earlier today, I spoke to the chief executive of the trust, who was not in post during the period examined in the report. I made it clear how seriously I take this report and the failures that were uncovered, and I reinforced the message that the recommendations must be acted on promptly, but as the report identifies, there are also wider lessons that must be learned, and it sets out a series of actions that should be considered by all trusts that provide maternity services. I have asked NHS England to write to all of those trusts, instructing them to assess themselves against these actions, and NHS England will set out a renewed delivery plan that reflects those recommendations.

I am also taking forward the specific recommendations that Donna Ockenden has asked me to. The first is on the need to further expand the maternity workforce. Just a few days ago, the NHS announced a £127 million funding boost for maternity services across England. That will bolster the maternity workforce even further, and fund programmes to strengthen leadership, retention and capital for neonatal maternity care.

Secondly, we will take forward the recommendation to create a working group, independent of the maternity transformation programme, with joint leadership from the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists.

Finally, Donna Ockenden said that she endorses the proposals that I announced in January to create a special health authority to continue the maternity investigation programme that is run by the Healthcare Safety Investigation Branch. Again, we will take her proposals forward, and the SHA will start its work from April next year.

I thank Donna Ockenden and her whole team for the forensic and compassionate approach that she has taken throughout this distressing inquiry. The report has given a voice at last to those families who were ignored and so grievously wronged, and it provides a valuable blueprint for safe maternity care in this country for years to come.

Finally, I pay tribute to the families whose tireless advocacy was instrumental to the review being set up in the first place. I cannot imagine how difficult it must have been for them to come forward and tell their stories, and the report is a testament to the courage and fortitude that they have shown in the most harrowing of circumstances.

This report is a devastating account of bedrooms that are empty, families that are bereft and loved ones taken before their time. We will act swiftly, so that no families have to go through the same pain in the future. I commend this statement to the House.

The Secretary of State is quite right that this is a very important statement, so I will offer the shadow Minister, Feryal Clark, six minutes.

I thank the hon. Lady for her remarks. It is not often that we get to say this in this Chamber, but I agree wholeheartedly with what she has just shared with the House. She is absolutely right to talk about this as a fight for justice and to say that if these brave families had not been so persistent in coming forward with what was done to them and what went wrong, the inquiry might never have happened. She is also right to talk about institutional failure at the trust, which the first report set out in some detail and which we are seeing in much more detail today.

The hon. Lady talked, rightly, about patient safety. She will know that the Government have already set out plans to appoint a patient safety commissioner; that appointment will be made soon, but we need to do much, much more. That is why it was right to accept all the interim report’s recommendations, including seven immediate and essential actions and 27 local actions. I can tell the House that the trust has implemented all the actions set out in the interim report; that was backed at the time by £95 million in extra funding. As I said a moment ago, the final report quite rightly makes many more recommendations, which have all been accepted and which are backed by funding of at least £127 million, much of which will go to workforce.

The hon. Lady is right about the need to increase the size of the workforce, especially with respect to midwives. Last year’s acceptance figures for student nurses and midwives were, I think, the highest that the country had seen in decades, but clearly there is much more to do.

We now come to the Chair of the Health and Social Care Committee.

Today’s report goes beyond my darkest fears. When I commissioned it as Health Secretary in 2016, I was approached by 23 families; we have heard today that more than 200 babies might have been alive today if better care had been provided. I thank Donna Ockenden and her team for an incredibly thorough investigation. I also thank the Health Secretary for his compassionate and comprehensive response to the House today.

Donna Ockenden does not use the word “recommendation”; she talks about immediate and essential actions. What is the Secretary of State’s deadline for the implementation of those actions? That is something that every expectant mother in the country desperately wants to know.

May I gently say to the Secretary of State that while I warmly welcome more midwives and more doctors, that approach is not consistent with voting down today the Lords amendment to the Health and Care Bill that would make sure that we never have those shortages again?

Finally, I pay tribute to Richard Stanton and Rhiannon Davies and to Kayleigh and Colin Griffiths. Richard and Rhiannon came to talk to me about their daughter Kate, who died in 2009; Colin and Kayleigh’s daughter Pippa died in 2016, when I was Health Secretary. Because of the blame culture and the culture of fear in the NHS, it was left to them and many other families to fight for justice. Can this be the last time that we put that burden on the shoulders of bereaved families? Can we build a culture in the NHS that is open and transparent and that accepts that things go wrong, but is hungry to learn from mistakes so that we never again repeat the tragedies?

I very much agree. I want to acknowledge that the report ultimately took place because of my right hon. Friend’s decision to ask Donna Ockenden to do the independent review, but he is absolutely right that he, in turn, did so because of the bravery of Rhiannon Davies and Richard Stanton, of Kayleigh and Colin Griffiths and of the many other families who came to see him.

My right hon. Friend asked about the immediate and essential actions. The interim report sets out seven such actions; the trust has implemented them all, and across the NHS they are either fully or partially implemented. The final report also recommends such actions; their implementation has already begun. Of course, we have just received the report, but I have asked for a timetable of when it will all be done. I want to see it done as quickly as possible.

My right hon. Friend’s point about workforce is very important. I hope he welcomes the fact that, for the first time, the NHS has been asked to set out a 15-year workforce plan.

I join colleagues across the House in thanking all the families who have bravely come forward to share their experiences, particularly Kayleigh, Colin, Rhiannon and Richard, whose persistence has led to the review. I hope that women and babies in Shropshire, Telford and the Wrekin and across the UK will be safer in future as a result of their bravery.

I thank Donna Ockenden and her team for their thoroughness in reviewing so many tragic cases. I am sure that the Secretary of State agrees that this can never be allowed to happen again and that the deaths of these 201 babies must not be in vain. This must be a turning point for maternity services in England.

Donna Ockenden has endorsed the findings of the Health and Social Care Committee and recommended that an immediate investment of £200 million to £350 million per annum is required to keep women safe. I welcome the Secretary of State’s guarantees that the immediate and essential actions will be implemented, but may I ask whether he can commit the additional resources recommended by Donna Ockenden today?

I thank the hon. Lady for her comments. I assure her that constituents throughout Shropshire, Telford and the Wrekin, and indeed families across England, will be safer as a result of those brave families coming forward and this report.

On resources, the hon. Lady will have heard me talk about the £95 million given at the time of the interim report, plus the £127 million given for maternity services in the past few days. We will keep that under review.

I thank the Secretary of State for his very welcome statement and the Under-Secretary of State, my hon. Friend the Member for Lewes (Maria Caulfield), for her excellent work. I pay tribute to my right hon. Friend the Member for South West Surrey (Jeremy Hunt) for everything that he has done for patient safety; he has led the way, and I am so grateful.

Does the Secretary of State believe that what we have seen at Shrewsbury and Telford Hospital NHS Trust is indicative of a culture in which senior management were unaccountable, no one felt responsible, failings were minimised, poor care was normalised and women’s voices were not heard? Will he do everything he can to increase the accountability of senior management across the NHS so that that institutional blindness can never again cause such harm to those who put their trust in the NHS?

Let me first thank my hon. Friend for her approach and her role in helping to make the report happen, and for the way in which she has worked with me, and with Ministers in my Department, on this most important of issues. She is right to talk about the importance of culture, especially given that, as the report makes clear, the voices of women were not heard time and again. I want to reassure her that we will implement all the report’s recommendations, but, more broadly, that women’s voices will be at the heart of the upcoming women’s health strategy.

Today is an important day for maternity safety, and we rightly pay tribute to the families directly affected, so many of whom have given evidence to the Ockenden review.

James Titcombe, who lost his baby son Joshua during the Morecambe Bay maternity scandal, has said that one of the most harmful experiences for the Morecambe Bay families was

“seeing influential people in the maternity world diminish… the…findings”

of the investigation report. I join James Titcombe in saying that we must not allow that to happen with this report. I urge the Secretary of State to ensure that the bereaved families are allowed a process of truth, reconciliation and healing, rather than any denial of the truth of what took place.

I agree with the hon. Lady, and she is right to raise the importance of the Morecambe Bay investigation. That report, which I believe was completed in 2015, contained 44 recommendations. Eighteen recommendations that were specifically for the trust have been implemented, and the 26 for the wider NHS are in the course of being implemented.

I thank my right hon. Friend for both the tone and the substance of his response to this devastating report. Let me also add my voice to the consensus throughout the House that the way in which this is handled is vital, and that we must ensure that the NHS takes Donna Ockenden’s recommendations on board. She and her team of more than 90 experienced clinicians are properly being thanked for the work that they have done. They have painstakingly reviewed these cases going back some 20 years, which must have been harrowing for them, as of course it has been for all the families so tragically affected who have had to relive their tragedy.

In particular, I want to praise the courage and tenacity of Rhiannon Davies and Richard Stanton, who were my constituents when they lost their baby Kate in truly awful, and tragically avoidable, circumstances. It was they who kept pressing for answers from Shrewsbury and Telford Hospital NHS Trust. That led me to take them to see the then Health Secretary, my right hon. Friend the Member for South West Surrey (Jeremy Hunt), who agreed to launch this review five years ago. They are no longer my constituents, and I understand that they are now understandably keen to focus their attention on their family, having been living with this trauma since 2009.

I have some questions for my right hon. Friend the Secretary of State. Does he recognise that the Ockenden review has raised fundamental questions for maternity services across the NHS over the culture of so-called normal birth, and that a focus on targets, under successive Governments, rather than on patient outcomes, can distort clinical best practice and, tragically, patient safety? Following his discussion with the trust’s current chief executive, which he has mentioned, is he satisfied that the current management and clinical teams have accepted the “local actions for learning” recommendations in the initial Ockenden report, and are committed to studying and rapidly implementing all further recommendations specific to the trust? Finally, what reassurance can he give the thousands of expectant mothers in Shropshire, Telford and Wrekin that the maternity services there are safe, and that patient safety is paramount?

I thank my right hon. Friend for the way in which he has worked with the Department and with my predecessor in representing his constituents throughout this investigation. He referred to “so-called normal birth” in his question, and he was right to do so: the only normal birth is a safe birth, which is what the NHS should be working towards, but that did not happen in this trust. The report has made that absolutely clear. Just as important are its recommendations, including some for my right hon. Friend’s local NHS trust. I can reassure him—partly as a result of my conversation earlier today with the current chief executive—that all the recommendations in the interim report have been implemented by his local trust, and all those in this report have been accepted.

Let me start by paying tribute to all the families affected, and thanking Donna Ockenden and her team for their recommendations.

More midwives are leaving the profession than are joining it. We cannot run equally safe services in all NHS trusts without appropriate staffing levels. I therefore hope that the Secretary of State will be able to give further details of what the Government are doing to ensure that there are safe staffing levels in all trusts to provide care for pregnant women.

The hon. Lady is right to talk about the importance of having the right workforce, and certainly more midwives. I can tell her than last year there were 30,185 acceptances for nursing and midwifery courses, the highest number in a decade. Recruitment is being supported by some of the extra funding that I have talked about today. The Government have established grants enabling students to take courses, and, where appropriate, are also focusing on international recruitment.

This courageous report makes clear that keeping caesarean section rates artificially low contributed to babies dying. I am pleased that, following a recommendation from the cross-party Health and Social Care Committee, NHS trusts are no longer being assessed on performance for their caesarean rates, but will the Secretary of State go further? Will he ensure that we look at where caesarean section rates remain artificially low in trusts, so that this dangerous “normal births” ideology is eradicated from the NHS once and for all?

The answer is yes.

I, too, pay tribute to the families named in what is a truly shocking report.

I am sorry, but I have not read all the recommendations, so may I ask the Secretary of State whether, as well as identifying issues relating to the culture in this particular trust, the report includes recommendations concerning governance for boards? Boards have a key role in holding their executives to account. Will he be writing to them to make them aware of their responsibilities in that regard? May I also ask him what the implications are for the national clinical audit of the confidential inquiries into maternal and infant deaths?

If I may, I will write to the hon. Lady about the national clinical audit. As for her important point about boards, the report refers to their importance and the importance of ensuring that the people on them are vetted, understand their responsibilities, and have the information that they need in order to fulfil those responsibilities. In, I think, 2014 or thereabouts, the Care Quality Commission changed the rules relating to NHS trust board members, requiring them to meet a new “fit and proper” test.

It is impossible to think about these lost babies, lost lives, and damaged families without becoming very upset and then very, very angry. However, I know from the work I have been doing with midwives and families, mums and dads, in the last six months or so that this does not involve just one trust. We have thousands of midwives marching on the streets. During the pandemic, mums were taking to social media, feeling that they were being marginalised and their voices were not being heard. Midwives tell me that they did not want to speak out before because they did not want to frighten the mums and dads in their charge, and that is why they often feel that they are not heard themselves. So we have to help them. How will the NHS and the Government reassure pregnant women and help the midwives to reassure them, given that all this is in the news at the moment, and how can we prevent other maternity services from failing?

My hon. Friend has raised a very important point. Hundreds of thousands of births are delivered through the NHS each year, and the vast majority are completely safe, as I myself have found and as many other Members have found, including my hon. Friend. What we have heard about today is what happens when it goes wrong, and goes tragically wrong, but especially when that was avoidable.

My hon. Friend was right to talk about the importance of considering other trusts. This report focuses on one trust, but we know that there was a problem in Morecambe Bay and that an independent investigation is taking place in East Kent. There is action to be taken by all trusts. That is why I think it is so important for the NHS to act on the recommendations for the wider NHS, and for me to act on the recommendations for my Department. We will certainly be taking action and so will the NHS.

I thank the Secretary of State for his statement. Not one person could help but be moved by that account or by his sincerity in dealing with this horrific situation. I also want to commend all those involved in the Ockenden report for their work on this issue. Our hearts break for the little babies, the mums and dads and the family units who have been impacted by these horrendous practices, and today we remember and commend the bravery of the families who had the courage to speak out. Given the findings and the negative cloud that will hang over all those who work in maternity services, will the Secretary of State take this opportunity to thank the maternity teams throughout this United Kingdom who, day in and day out, bring new life into this world in a compassionate and professional manner? I am thinking of the wonderful services at Craigavon Area Hospital in my own constituency. I know that those who work there will be saddened today by what they are hearing in the report, so I trust that the Secretary of State can commend them for the work that they do.

I join the hon. Lady in warmly thanking and commending the work of maternity teams throughout the United Kingdom for what they do, day in and day out, especially over the last two years of the pandemic, which has probably made it even harder than normal. I know that they will all welcome this report because they will want to see the very changes that are set out in it.

I would also like to thank the families for shining a spotlight on this. One of my children suffered from oxygen deprivation at birth, through what I now know were failings in my care. I was lucky, though, in my third pregnancy. By sheer fluke, the GP practice I was registered with had a wonderful community midwife. She was with me through my pregnancy and through the birth of my daughter and she took care of me afterwards. I was listened to, I was supported and I felt safe. I thank my right hon. Friend for taking on board these recommendations, but would he agree that every woman deserves that continuity of care? It can make a profound difference in outcomes for families, because they will have somebody by their side who understands them and they will not have to go through their medical history over and over again, often missing out vital pieces. We should have loftier ambitions. Will my right hon. Friend try to make sure that every woman has the opportunity to have their own midwife with them all the way?

Yes, I agree very much with my hon. Friend and I thank her for sharing with the House her own valuable experiences. She is right to talk about the importance of continuity of care, and that is part of our maternity transformation plan.

I thank the Secretary of State for the report, although it is sad that we have to have a report such as this in front of the House. I want to highlight a point and check whether we can do something about it. There are many good people working in our NHS, and the majority of people are probably there for the right reasons, but, unfortunately, due to the culture of institutional blindness that has been mentioned, or to bullying, they cannot whistleblow, and whistleblowers are not being protected. As a consequence, more and more of these types of reports are going to be required, not only on maternity services, because whistleblowers are being targeted and put down. I would ask that whistleblowers be protected and given the opportunity to have their concerns understood and heard.

The hon. Gentleman is absolutely right. One of the reasons we are creating the special health authority that I referred to earlier is to provide that independence, and also more protection for members of staff to come forward. For example, members of staff will be able for the first time to report things they are concerned about directly to the SHA, and it will have the right to investigate.

Many members from across the House have mentioned the incredible bravery of all the parents who fought for their babies, particularly Rhiannon Davies. Rhiannon is originally from mid-Wales, although she now lives in a constituency across the border. There are many women who live in mid-Wales who need to access the Shrewsbury and Telford Hospital NHS Trust, and I am concerned that they will hear about today’s report and be worried about the care that they will be receiving over the next few days. So, as well as implementing the Ockenden review in full, will the Secretary of State please give his reassurance to those women in Wales who need to travel across the border for maternity services?

Yes, I can give my hon. Friend that reassurance. I can add that Donna Ockenden, in doing her work, looked at cases from Wales as well. The issue that my hon. Friend has raised has also been raised by my hon. Friend the Member for Montgomeryshire (Craig Williams), and I can give them both that assurance.

I thank the Secretary of State for his statement, for the obvious compassion that he has for all those involved, and for his support of the Ockenden report. I want to place on record my sympathy with all those parents who still grieve their loss, and for whom no report will never, ever soothe the pain. Will the Secretary of State confirm that the report into this dreadful spate of deaths will be made available to all hospital trusts across the United Kingdom, including Northern Ireland, to ensure that lessons are learned and that the 84 recommendations of the Ockenden report and any mechanisms of prevention can be understood and put in place UK-wide?

Yes, I can give the hon. Gentleman that assurance. We are more than happy to reach out to the Northern Ireland health service and to work proactively with it on improving maternity services in Northern Ireland.

I thank my right hon. Friend for his statement, and all the many Members present who have contributed to the process that has led to this report. Following the remarks by my hon. Friend the Member for Brecon and Radnorshire (Fay Jones), I have been working with my hon. Friend the Member for Montgomeryshire (Craig Williams), who sadly cannot be here today as he has important constituent business, to look at the cross-border nature of this inquiry in relation to his constituency, my constituency of Clwyd South, my hon. Friend’s constituency of Brecon and Radnorshire and others on the Welsh borders. Will my right hon. Friend reflect on the fact that there will be many concerned residents in Wales, alongside the victims outlined in this report, who need representation on this important issue?

Yes, I can give my hon. Friend, and my hon. Friend the Member for Montgomeryshire, who cannot be with us today, the reassurance that they seek.

My right hon. Friend said in his statement that the Care Quality Commission rated these maternity services inadequate for safety only in 2018, which is unacceptable. Can he assure the House that the CQC inspections are now rigorous enough that failings are picked up much earlier to prevent this type of thing from happening again?

I can assure my hon. Friend that there have already been a number of changes in the CQC’s approach, but I cannot give an assurance that it has changed enough, because this report has only just been published and it is important to me to follow through and ensure that, where relevant, the independent regulators are also making the changes set out in the report. To respond to an earlier question from the hon. Member for Enfield North (Feryal Clark), she was right to suggest that there should be an update from Ministers on progress following this report, and I will ensure that that happens. That picks up on this question about the CQC as well.

This House is united in our heartache over the lives lost and the lives destroyed, and over the women who were silenced and told that birthing had happened for centuries so they should shut up, or that it should happen as though in some sort of movie. I am afraid that, as an MP, I have concluded that NHS bureaucracy has a systemic problem of sexism, and I ask the Secretary of State to keep an eye on this nationally. I remember, after 36 hours of labour, being rushed to the operating theatre and being denied a C-section, then being rushed back an hour later and having a C-section, but only because my husband had noticed that my son’s heart rate had plummeted to almost non-existent. We must also prevent the unforgivable and unscientific locking out of loved ones across all health services. It compromises care and it is still happening in hospitals around the country across different types of care.

I thank my hon. Friend for saying what she has said in the way that she did, and also for talking about her own experience. She is absolutely right to emphasise the point that the NHS is there to care for anyone regardless of their gender, but when it comes to women in particular, I hope she agrees that this is precisely why the Government are right to want to set out—as we will do shortly and for the first time ever—a detailed women’s health strategy.