PARLIAMENTARY DEBATE
Maternity Safety Strategy - 28 November 2017 (Commons/Commons Chamber)

With permission, I will make a statement about the Government’s new strategy to improve safety in NHS maternity services.

Giving birth is the most common reason for admission to hospital in England. Thanks to the dedication and skill of NHS maternity teams, the vast majority of the roughly 700,000 babies born each year are delivered safely, with high levels of satisfaction from parents. However, there is still too much avoidable harm and death. Every child lost is a heart-rending tragedy for families that will stay with them for the rest of their lives. It is also deeply traumatic for the NHS staff involved. Stillbirth rates are falling but still lag behind those in many developed countries in Europe. When it comes to injury, brain damage sustained at birth can often last a lifetime, with about two multi-million pound claims settled against the NHS every single week. The Royal College of Obstetricians and Gynaecologists said this year that 76% of the 1,000 cases of birth-related deaths or serious brain injuries that occurred in 2015 might have had a different outcome with different care. So, in 2015, I announced a plan to halve the rate of maternal deaths, neonatal deaths, brain injuries and stillbirths, and last October I set out a detailed strategy to support that ambition.

Since then, local maternity systems have formed across England to work with the users of NHS maternity services to make them safer and more personal; more than 80% of trusts now have a named board-level maternity champion; 136 NHS trusts have received a share of an £8.1 million training fund; we are six months into a year-long training programme and, as of June, more than 12,000 additional staff have been trained; the maternal and neonatal health safety collaborative was launched on 28 February; 44 wave 1 trusts have attended intensive training on quality improvement science and are working on implementing local quality improvement projects with regular visits from a dedicated quality improvement manager; and 25 trusts were successful in their bids for a share of the £250,000 maternity safety innovation fund and have been progressing with their projects to drive improvements in safety.

However, the Government’s ambition is for the health service to give the safest, highest-quality care available anywhere in the world, so there is much more work that needs to be done. Today, I am therefore announcing a series of additional measures. First, we are still not good enough at sharing best practice. When someone flies to New York, their friends do not tell them to make sure that they get a good pilot. But if someone gets cancer, that is exactly what friends say about their doctor. We need to standardise best practice so that every NHS patient can be confident that they are getting the highest standards of care.

When it comes to maternity safety, we are going to try a completely different approach. From next year, every case of a stillbirth, neonatal death, suspected brain injury or maternal death that is notified to the Royal College of Obstetricians and Gynaecologists’ “Each Baby Counts” programme—that is about 1,000 incidents annually—will be investigated not by the trust at which the incident happened, but independently, with a thorough, learning-focused investigation conducted by the healthcare safety investigation branch. That new body started up this year, drawing on the approach taken to investigations in the airline industry, and it has successfully reduced fatalities with thorough, independent investigations, the lessons of which are rapidly disseminated around the whole system.

The new independent maternity safety investigations will involve families from the outset, and they will have an explicit remit not just to get to the bottom of what happened in an individual instance, but to spread knowledge around the system so that mistakes are not repeated. The first investigations will happen in April next year and they will be rolled out nationally throughout the year, meaning that we will have complied with recommendation 23 of the Kirkup report into Morecambe Bay.

Secondly, following concerns that some neonatal deaths are being wrongly classified as stillbirths, which means that a coroner’s inquest cannot take place, I will work with the Ministry of Justice to look closely into enabling, for the first time, full-term stillbirths to be covered by coronial law, giving due consideration to the impact on the devolved Administration in Wales. I would like to thank my hon. Friend the Member for East Worthing and Shoreham (Tim Loughton) for his campaigning on this issue.

Next, we will to do more to improve the training of maternity staff in best practice. Today, we are launching the Atain e-learning programme for healthcare professionals involved in the care of newborns to improve care for babies, mothers and families. The Atain programme works to reduce avoidable causes of harm that can lead to infants born at term being admitted to a neonatal unit. We will also increase training for consultants on the care of pregnant women with significant health conditions such as cardiovascular disease.

We know that smoking during pregnancy is closely correlated with neonatal harm. Our tobacco control plan commits the Government to reducing the prevalence of smoking in pregnancy from 10.7% to 6% or less by 2022. Today, we will provide new funding to train health practitioners, such as maternity support workers, to deliver evidence-based smoking cessation according to appropriate national standards.

The 1,000 new investigations into “Each Baby Counts” cases will help us to transform what can be a blame culture into the learning culture that is required, but one of the current barriers to learning is litigation. Earlier this year, I consulted on the rapid resolution and redress scheme, which offers families with brain-damaged children better access to support and compensation as an alternative to the court system. My intention is that in incidents of possibly avoidable serious brain injury at birth, successfully establishing the new independent HSIB investigations will be an important step on the road to introducing a full rapid resolution and redress scheme, to reduce delays in delivering support and compensation for families. Today, I am publishing a summary of responses to the consultation, which reflect strong support for the key aims of the scheme: to improve safety, to improve patients’ experience and to improve cost-effectiveness. I will look to launch the scheme, ideally, from 2019.

Finally, a word about the costs involved. NHS Resolution spent almost £500 million settling obstetric claims in 2016-17. For every £1 the NHS spends on delivering a baby, another 60p is spent by another part of the NHS on settling claims related to previous births. Trusts that improve their maternity safety are also saving the NHS money, allowing more funding to be made available for frontline care. To create a strong financial incentive to improve maternity safety, we will increase by 10% the maternity premium paid by every trust under the clinical negligence scheme for trusts, but we will refund the increase, possibly with an even greater discount, if a trust can demonstrate compliance with 10 criteria identified as best practice on maternity safety.

Taken together, these measures give me confidence that we can bring forward the date by which we achieve a halving of neonatal deaths, maternal deaths, injuries and stillbirths from 2030—the original planned date—to 2025. I am today setting that as the new target date for the “halve it” ambition. Our commitment to reduce the rate by 20% by 2020 remains and, following powerful representations made by voluntary sector organisations, I will also include in that ambition a reduction in the national rate of pre-term births from 8% to 6%. In particular, we need to build on the good evidence that women who have “continuity of carer” throughout their pregnancy are less likely to experience a pre-term delivery, with safer outcomes for themselves and their babies.

I would not be standing here today making this statement were it not for the campaigning of numerous parents who have been through the agony of losing a treasured child. Instead of moving on and trying to draw a line under their tragedy, they have chosen to relive it over and again. I have often mentioned members of the public such as James Titcombe and Carl Hendrickson, to whom I again pay tribute. But I also want to mention members of this House who have bravely spoken out about their own experiences, including my hon. Friends the Members for Colchester (Will Quince), for Eddisbury (Antoinette Sandbach) and for Banbury (Victoria Prentis), as well as the hon. Members for Lewisham, Deptford (Vicky Foxcroft), for Washington and Sunderland West (Mrs Hodgson) and for North Ayrshire and Arran (Patricia Gibson). Their passionate hope—and ours, as we stand shoulder to shoulder with them—is that drawing attention to what may have gone wrong in their own case will help to ensure that mistakes are not repeated and others are spared the terrible heartache that they and their families endured. We owe it to each and every one of them to make this new strategy work. I commend this statement to the House.

I am grateful to the Secretary of State for the advance copy of his statement. At the outset, may I pay tribute, as he has done, to the hon. Members who have spoken out so movingly in recent months about baby loss? They include, as he has said, the hon. Members for Colchester (Will Quince), for Eddisbury (Antoinette Sandbach), for Banbury (Victoria Prentis) and for North Ayrshire and Arran (Patricia Gibson), and my hon. Friends the Members for Lewisham, Deptford (Vicky Foxcroft) and for Washington and Sunderland West (Mrs Hodgson). They are all a credit to the House.

Our national health service offers some of the best neonatal care in the world, and the progress set out by the Secretary of State today is a tribute to the extraordinary work of midwives and maternity staff across the country. We welcome his announcement that all notifiable cases of stillbirth and neonatal death in England will now receive an independent investigation by the healthcare safety investigation branch. That is an important step, which will help to bring certainty and closure to hundreds of families every year.

We also welcome the move by the Secretary of State to allow coroners to investigate stillbirths. May I assure him that the Opposition stand ready to work constructively with him to ensure the smooth and timely passage of the relevant legislation, should he and the Government choose to bring any before the House? I also pay tribute to the work carried out by the team at the University of Leicester that leads on the perinatal aspects of the maternal, newborn and infant clinical outcome review programme, which provided the evidence for today’s announcement.

The number of deaths during childbirth has halved since 1993, saving about 220 lives a year, but we welcome the Secretary of State’s ambition to bring forward to 2025 the target date for halving the rate of stillbirths, neonatal deaths, maternal deaths and brain injuries that occur during or soon after birth. If that target is to be delivered, however, it is essential that NHS units providing these services are properly resourced and properly staffed. We welcome the launch of the Atain e-learning programme, as well as the increased training for consultants on the care of pregnant women with significant health conditions. We also welcome the emphasis on smoking cessation programmes, but we should remind the Secretary of State that public health budget cuts mean that many anti-smoking programmes have been cut back across the country.

The Secretary of State will know that the heavy workload in maternity units was among the main issues identified by today’s study, which found that “service capacity” issues in maternity units affected over a fifth of the deaths reviewed. Earlier this year, our research revealed that half of maternity units had closed their doors to mothers at some point in 2016, with staffing and capacity issues being the most common reasons for doing so. The Royal College of Midwives tells us that we are about 3,500 midwives short of the number needed. A survey published by the National Childbirth Trust this year showed that 50% of women having a baby experienced what the National Institute for Health and Care Excellence describes as a red flag event, which is an indicator of dangerously low staffing levels, such as a women not receiving one-to-one care during established labour.

We therefore believe that the NHS remains underfunded and understaffed. I would be grateful to the Secretary of State if he told us what further action he intends to take to ensure that maternity services are properly funded and to address the staffing shortages as part of a full strategy to improve safety across the board. The NHS has excellent psychological and bereavement support services for women affected by baby loss, but we all know that the quality of those services remains variable across the country. Indeed, we are still a long way from full parity of esteem for mental health in neonatal care. What action does the Secretary of State intend to take to plug these gaps?

Overall, this welcome set of announcements from the Secretary of State may help the NHS to provide the best quality of care for all mothers and their babies. The Opposition look forward to working constructively with the Secretary of State and the Government, but I hope he can reassure us that they will provide the resources that NHS midwives and their colleagues need to deliver on these ambitions.

I thank the shadow Health Secretary for the constructive tone of his response to the statement. I think he is right to point out both the achievements that have been made over many years, but also the challenges ahead. We have about 1,700 neonatal deaths every year—that has actually fallen by 10% since 2010—but behind that figure, there is variation across the country. For example, our best trust has about three deaths in 1,000, but in other trusts the figure can be 10 in 1,000, which is more than three times as many neonatal deaths. That shows we are not as good as we need to be at spreading best practice. Today’s announcement is really about ensuring that we can confidently look every expecting mum in the eye and say, “You are getting the very highest standards of care that we are able to deliver in the NHS.”

I thank the hon. Gentleman for his offer to co-operate on any legislation needed to expand the scope of inquests to full-term stillbirths, and we will get back to him on that. I also thank him for raising the issue of bereavement services. I spoke to a bereavement midwife this morning, and I think bereavement midwives are among the most extraordinary people working in the whole NHS. We do have a programme to improve the consistency of bereavement services and to roll out the use of bereavement suites across the NHS; our best trusts have such suites, but by no means all of them do.

The hon. Gentleman was absolutely correct to raise the issues of both funding and staffing. We have seen an increase of 1,600 in the number of midwives since 2010, which is a rise of 8%, and an increase of 600 in the number of obstetricians and doctors working in maternity departments, which is a rise of about 13%, but we need more. There are lots of pressures across the NHS, and we also have to fund the extra midwives and doctors that we need. There was a welcome boost for the NHS in the Budget, with an extra £1.6 billion available for the NHS next year. However, looking forward to the next 10 years and all the pressures coming down the track for the NHS—with a growing birth rate, but also with an ageing population—I do not pretend that we will not have to revisit the issue of NHS funding and find a long-term approach. Probably the most appropriate time to do that will be when we come to the end of the five year forward view and start to think about what happens following that. If we are to put more money into the NHS, we need to have the doctors, midwives and nurses to spend that money on, which is why, in the past year, the Government have committed to a 25% increase in the number of nurse training places and a 25% increase in the number of medical school training places.

My final point for the hon. Gentleman is that, although we have lots of debates in this House in which we take different positions in relation to the NHS, one thing we can be united on is our aspiration, which is shared across the House, that the NHS should be the safest healthcare system in the world, and I very much thank him for his support on that.

Order. This is an extremely important and sensitive matter, and we appreciate the statement on it. However, the business to follow—the final day of debate on the Budget—is also extremely important, and no fewer than 67 right hon. and hon. Members have indicated a wish to speak. Exceptionally, therefore, I may not feel able to call everybody on this statement. In any event, there is a premium on brevity from Back Benchers and Front Benchers alike.

I warmly welcome the Secretary of State’s announcements today, including the move to allow coroners to investigate full-term stillbirths. Will he set out the current waiting time for post-mortems for infants because, as he will be aware, there is a shortage of the very highly specialised pathologists who carry out this vital work?

I do not have that information to hand, but I will find out for my hon. Friend and let her know.

Last month’s debate on baby loss has been mentioned, and I too took part in it, although I have thankfully been spared the pain suffered by some Members of the House. Such a debate really helps to bring out for everyone on both sides of the House how important this issue is, and I do not think there will be anyone who does not welcome this statement and the ambition it shows.

In Scotland, we had a higher stillbirth, neonatal and perinatal death rate in 2012, but our new chief medical officer was actually an obstetrician, and that may have led to the change of focus in 2013, when she established the maternity and children quality improvement collaborative and the national stillbirth group—all as part of the Scottish patient safety initiative—as well as the neonatal managed clinical networks across Scotland. That has enabled us to drop our stillbirth rate by more than a quarter, and to drop our neonatal death rate by 50%.

This has been achieved despite the challenges we face of really difficult geography, including getting people off islands. It is easy to spot the woman who has a history of difficult births or to spot a woman with comorbidities, such as obesity or diabetes, but anyone who has been involved in birth knows that even the healthiest pregnancy can go wrong at the last minute. For us, as in rural parts of the north and west of England, there are transport issues in relation to how women with problems during labour are identified and transported if a higher specialism is required, and those issues must be looked at.

This is very much about the provision of neonatal services, including the movement of patients, and the availability of expertise and of neonatal intensive care units. However, as came out several times during the debate on baby loss, another issue is that of pre-term birth and stillbirth, so this is also about trying to change some of those things. After Scotland’s recent review in February, the focus will be on the consistent monitoring of growth, as a failure to thrive can identify a third of impending stillbirths; the continuity of care, which the Secretary of State has referenced; and especially smoking. Although the Secretary of State mentioned getting smoking rates down—and in Scotland, sadly, they are higher—the rate in the most deprived communities is more than four times that in the least deprived communities. That has an impact on every level of child loss.

Finally, on research, it is important that we learn, for example from the new information about women sleeping on their side in the last trimester. We need to fund the research to learn those things and then share the information—

Order. I have the highest regard for the hon. Lady, who is a considerable medical authority. I gave her a little leeway, but I say very gently that not only did she exceed her time by a minute, but she pursued her usual, rather discursive approach. In these situations, what is required is a question or a series of questions with a question mark or a series of question marks, rather than general analysis. We will leave it there for now. I say that in the most good-natured spirit to the hon. Lady.

I call Antoinette Sandbach.

I forgot that we had heard from the hon. Member for Central Ayrshire (Dr Whitford), but we had not yet heard from the Secretary of State. Apologies.

I actually agreed with everything the hon. Member for Central Ayrshire said. I will give a rather more brief response.

Order. As I have just been advised by the distinguished Clerk at the Table, who swivelled round so to advise me, there is really no need for a response, because there was no question. However, I will indulge the right hon. Gentleman to the point of a paragraph.

Let me simply say that there is an excellent Scottish patient safety programme. Given that one of the main objectives behind the statement is to share best practice, I would be very happy to talk to the chief medical officer in Scotland and to Jason Leitch about how we can exchange information and learn from each other’s systems.

As every parent who has lost a child knows, what they want most is answers. I therefore congratulate the Secretary of State on bringing forward the healthcare safety investigation branch, because such independence will be crucial in gaining the buy-in of parents and in their knowing what has happened in their particular case. How will the learning from those investigations be shared?

I thank my hon. Friend for her extraordinary campaigning on this issue. Yes, we want parents to get the answer more quickly, but we also want to be able to answer the question that every parent asks: “Can you guarantee that this won’t happen again?” The investigators will have an explicit dual remit: to get to the bottom of what happened, but also to spread that message around the system so that the same mistake is not repeated. That is the objective of setting up a new team of people to do this.

My constituents Jack and Sarah Hawkins have spoken bravely about the tragic death of their daughter Harriet due to failures of care. Members may have heard them this morning. I spoke to Jack earlier and am pleased to tell the Secretary of State that they feel listened to and heard. They and I very much welcome his statement and his support for extending the power of coroners. However, Jack and Sarah need to be able to stop fighting and to begin healing, so I ask the Secretary of State to urge his colleagues at the Ministry of Justice to support the Bill introduced by the hon. Member for East Worthing and Shoreham (Tim Loughton) to bring about that change as soon as possible.

Through the hon. Lady, I express my thanks to Jack and Sarah for bravely telling their story this morning in the media, which was incredibly moving and touched a lot of hearts. With respect to allowing inquests into full-term stillbirths, our objective is to move as quickly as any legislative vehicle allows. If I am able to work closely with my hon. Friend the Member for East Worthing and Shoreham (Tim Loughton) to do that, that is exactly what I want to do.

I very much welcome the Secretary of State’s statement and congratulate him on it. Does he agree that the vast majority of grieving parents, if not all, not only want to know why, but want to know that their child’s life, however short, will have had meaning by ensuring that we learn lessons from them not as a statistic, but as a baby? That is why the independent investigation unit is so important. We must learn the lessons not just in one trust, but across the whole NHS and spread that learning to ensure that as few people as possible go through this emotional personal tragedy.

My hon. Friend is absolutely right. As he knows, because he has spoken so movingly on this subject many times, there is absolutely nothing we can do to make up for the searing loss of losing a loved one—a baby. It is the worst thing any parent can go through. We can at least give them the commitment that we will learn. If we are honest, we do not do so at the moment, because we sometimes wait 10 years for a court case to be settled, and even then it is not always clear to me that the lessons of what happened are properly learned around the system. This statement is an attempt to change that.

I very much welcome the Secretary of State’s approach to more openness and transparency in the NHS around baby deaths. However, he will remember signing a letter in May 2016, along with the then Secretary of State for Communities and Local Government and the then Secretary of State for Justice, on an independent inquiry into the baby ashes scandal in Hull. That inquiry has never happened and parents still do not have the answers about what happened in the NHS and Hull City Council in respect of their babies’ ashes. Will the Secretary of State recommit to that independent inquiry going ahead with his permission?

I am happy to recommit to that. I apologise to the hon. Lady and her constituents for the delay. I will look into what happened right away.

The hon. Member for Nottingham South (Lilian Greenwood) pre-empted my question about my Bill and coroners. I make the offer to sit down with the Secretary of State and his draftsman to decide on the wording of my private Member’s Bill, which will be debated on 2 February, as the fastest way to achieve his goals and get the solution that all Members of the House want.

I am happy to do that and am most grateful for that very generous offer.

I am sure that the Secretary of State will realise that, even after all these years, when my wife and I hear news like what we heard this morning, it takes us back to our first baby daughter, who died at birth. After that, we had four healthy children and 10 grandchildren, but we still go back to that awful time. Our baby was sickly; it was not about poor care. We care very much about people who lose their children. As a constituency Member of Parliament, I am getting increasingly worried about rationalisations in which maternity units get further and further away from where the main population live. I also get very worried when we do not give our midwives and doctors our full support to give them the morale to do that difficult job.

We must give doctors, nurses and midwives our full support, because they do an extraordinary job. Sometimes there are difficult issues and the centralisation of certain maternity services can improve patient safety if it means that there is round-the-clock consultant cover and so on. In my experience, the most important thing is to spot the most risky births early in the process. I am not a doctor, but there is sometimes an assumption that it is all about what happens at the moment of labour when women go into hospital. Actually, a lot of this is about thinking earlier in the process about higher risk mums—mums who smoke and mums from lower socioeconomic backgrounds—and intervening earlier. That will be important for the hon. Gentleman’s constituents and for mine.

I can absolutely confirm that. This follows a very interesting discussion on that topic we both had at lunch. My hon. Friend is right that the key is early intervention. Also, we know that continuity of carer makes a very big difference. If, well ahead of labour, people can meet the midwives who will be delivering their child, that can help reassure people and lead to safer births.

This is a very welcome statement. The Secretary of State will know of the very disturbing cases over the past few years in the Pennine health trust. Will he make space within the legislation for retrospective investigations where there have been a number of cases, as in the Pennine trust?

I will look into that very carefully. I am satisfied that there is strong new leadership at the Pennine trust and that it is being turned around, but it has told me about some of the cases to which the hon. Gentleman refers. They are of very great concern, and we absolutely must do everything we can to give answers to bereaved families.

As a bereaved parent, but also as a lawyer who has conducted many inquests, I ask the Secretary of State to consider two points. The first is the fact that not many families will need an inquest to determine what went wrong during the birth of their child. Secondly, will he commit to the training of special coroners, just as we have in military inquests, to ensure that those who deal with these very sad cases are the best equipped people to do so? Finally, on behalf of the all-party group on baby loss, may I thank him for today’s announcement and encourage him in his work to make maternity care kinder, safer and closer to home—and may I encourage him to save Horton General Hospital?

First, may I apologise to my hon. Friend, because I should have mentioned her in my statement as someone who has spoken very passionately and movingly on this topic in the House? I will take away her point about specialist coroners, because we are now going to have specialist investigators, which we have never had before. I would make one other point. I hope she does not think I am doing down her former profession, but really when people go to the law, we have failed. If we get this right—if we can be more open, honest and transparent with families earlier on—it will, I hope, mean many fewer legal cases, although I am sure that the lawyers will always find work elsewhere.

I welcome the Secretary of State’s statement, like many others in the Chamber. He talked several times about learning lessons. As he knows, a recent report has highlighted that in my own trust, the East Sussex Healthcare NHS Trust, there were 19 stillbirths last year, which is a far higher percentage than in the rest of the UK. In the spirit of learning lessons, will he agree to someone in the Department of Health examining why that is the case?

I absolutely undertake to look into that case and ensure a proper investigation into what is happening. The hon. Gentleman is right; in the end, we need to be much more open about this data, so I commend the trust for sharing the data publicly. Until we access such data, we will not know where the issues are that we need to solve.

With this vital new focus on safer births, will there be an opportunity to look at group B strep and other issues that if undetected in the later stages of pregnancy can result in baby loss?

I am very happy to undertake to do that.

I welcome the Secretary of State’s announcement, but will he reconfirm the advice from NICE that midwife-led birthing centres are safe under the appropriate circumstances? In areas such as Rochdale, where the birth rate has shot up dramatically following the closure of its maternity unit, the provision of something like a midwife-led centre would be the right approach.

I can absolutely confirm that for low-risk births that is the case, but it is also key to spot the births that are not low-risk, so that alternative provision can be made.

Will the Secretary of State do everything possible to spread across the country the excellent “dads to be” courses that are part of the antenatal provision at Chelsea and Westminster and Kingston Hospitals? We know that they help solidify relationships between parents at a moment of strain and reduce family breakdown.

I am intrigued to hear that, because my three children were born at the Chelsea and Westminster, and my wife would have been delighted if I had done a “dads to be” course. I will certainly look into that course and, I am sure, actively promote it.

May I concur with my hon. Friend the Member for Rochdale (Tony Lloyd) and say that, although safety must be paramount, it would be wrong to see this as a reason to shut midwife-led units and, in particular, discourage home births for women likely to have a safe birth who chose to have the baby at home? Will the Secretary of State say something to make sure that those units are safe?

I am very happy to do that. Midwife-led units and home birthing are both part of the NHS maternity offer, but it is wrong to suggest that there is a conflict between patient safety and the choice made by mothers. No mother would ever actively make a choice to do something that was not the safest option for her and her child.

I welcome the statement, and I am glad that the Secretary of State mentioned the role of tobacco. Has he also considered the role of alcohol?

My hon. Friend is absolutely right to say that. The evidence is very clear about the damage done to foetuses and babies if there is too much—or, indeed, any—drinking by a mother. I did not mention it in the statement because we are focusing on smoking cessation training, but he is right to mention the issue.

The brand new maternity unit at Furness General Hospital will open shortly, thanks to the campaigning of the whole community, but it will be safer thanks to the Secretary of State’s personal commitment, thanks to the staff and thanks to the parents of Elleanor Bennett, Alex Brady, Chester Hendrickson, Joshua Titcombe and others who have campaigned tirelessly for local and national change. Will he join my calls for their struggle to be permanently commemorated within the new unit?

I am happy to do that. I think I have met most of those parents. The hon. Gentleman has been incredibly supportive to them locally—they have told me that. When Carl Hendrickson came to see me, he brought his 11-year-old son, and I offered for the son to wait outside, but he said no—he wanted his son to be with him. I think it was because he wanted his son to know that he had been to the top to try to understand why his child and his wife died because of mistakes in that maternity unit. The hospital has done an incredible turnaround job—we are all really proud of what it has done—and we are confident that it would not happen again, but that is not to say that there is not a huge amount more we all need to do.

I welcome the Secretary of State’s remarks and the overall tenor of the comments made so far. Does he agree that the most important thing for families who experience tragedy in childbirth is to receive the straight answers they deserve and to know that lessons will be learned where necessary?

I do agree. I have visited my hon. Friend’s trust in Torbay and have been very impressed with the learning I saw from the Sam Morrish case, which was a very sad story of where that did not happen initially. However, as I say, I think the trust has learned all those lessons extremely impressively.

I thank the Secretary of State for his statement and personal commitment. It is much appreciated. Will he confirm that part of the safety strategy includes ensuring that midwives on labour wards can take their breaks and rest periods and that midwife staffing levels on labour wards and post-section wards are checked, monitored and increased?

I agree that that is extremely important. I also extend through the hon. Gentleman a similar offer to the one I made to the hon. Member for Central Ayrshire (Dr Whitford), who speaks for the SNP: I am happy to pursue any collaboration possible between the Northern Irish and English healthcare systems to share best practice.

I welcome the measures that the Secretary of State has announced today and commend him and other colleagues for their sympathetic work. Without them, we would not be here today. I also want to mention Musgrove Park Hospital in my constituency, which is already demonstrating how much good work can be done. It has cut the number of stillbirths by a third in 18 months and has won awards for it. It has introduced a special app that people can use when they are on maternity leave, and it has introduced much-improved special sepsis management. It also has a ground-breaking maternity apprenticeship scheme.

Does the Secretary of State agree that sharing such best practice is the best way to ensure that everyone else can do some great work and that we do not have to hear about these terrible examples again?

I really enjoyed visiting Musgrove Park hospital on Friday. I thought that what it was doing about stillbirths was incredibly impressive: I had not seen anything like it before. That is, indeed, an example of fantastic practice that I would like to spread everywhere.