Ockenden Review of Maternity Care: Shrewsbury and Telford
(4 years, 10 months ago)
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Lucy Allan (Telford) (Con)
I am delighted to have been granted this Adjournment debate on this very important issue. I want to raise it because the issue deserves the platform that Parliament affords. It concerns the safety of women and babies receiving maternity care at hospitals in Shropshire. I raise that in the context of the Morecambe Bay trust inquiry into maternity deaths in 2015, which at the time was considered to be a one-off. What has come to light at Shrewsbury and Telford Hospital NHS Trust suggests that there may be systemic problems within the NHS and maternity care, and there are without doubt significant concerns about the lack of transparency and openness around what went wrong.
The Ockenden review was set up two and half years ago to look at 23 possible cases of maternity malpractice at the Shrewsbury and Telford Hospital Trust. So far there have been no formal published findings. However, in November 2019 interim findings were leaked to the media. Those findings show not only that had some very serious failings indeed been uncovered by the review, but that the scale of the malpractice, and the number of women and babies affected by it, exceeded anything that had been expected when the review was initiated.
The interim findings stated that there had been in excess of 40 avoidable maternity deaths and 50 brain-injured babies. NHS Improvement was given that information almost a year ago and appears to have kept quiet about the findings. The findings also make reference to “widespread failings, a toxic culture and a failure to learn lessons.” Since those findings were made public, many, many more women have come forward—women who knew nothing about a review being held. The review is now looking at over 600 cases of possible maternity care malpractice.
Those interim findings directly contradict what senior management were saying publicly at the time when the review was commissioned. Senior management claimed that this was all overblown by the media, that it was all historical, and that good practice was in place now. The chief executive claimed that concerns raised about the possible scale of malpractice were “scaremongering”—his word. Senior hospital management adopted the stance that “it simply couldn’t happen here.” The CEO said that the media, particularly the BBC, had it in for them; that is what they actually said to me, the MP. How, in that kind of environment, can lessons be learned if there is no acceptance that anything has gone wrong?
We had the same response from the authorities in Telford when the scale of child sexual exploitation in the town was revealed. That denial, or perhaps being in denial, seems to be the standard response from those in positions of authority—minimising the problem, blaming the media and depicting those affected as being in some way troublesome.
Let us compare the review from Shrewsbury and Telford Hospital NHS Trust with that from Morecambe Bay, where there were 11 avoidable baby deaths and one maternal death. The Morecambe Bay inquiry reported promptly, and the then Secretary of State, my right hon. Friend the Member for South West Surrey (Jeremy Hunt), came immediately to the House, made a statement, and apologised to the families. He pledged that lessons would be learned, and that the legacy of those tragic deaths would mean that such things could not happen again. My right hon. Friend is in the Chamber today, and I am grateful that he did not just accept the position taken by senior management, NHS bureaucrats, and officials from Shrewsbury and Telford NHS Hospital Trust at face value. I commend him for initiating the Ockenden review, and for his commitment to encouraging a culture of transparency and openness across the NHS. We must continue with that approach.
Jeremy Hunt (South West Surrey) (Con)
I wish to repay the compliment and thank my hon. Friend for her tireless campaigning on this issue. It is not easy publicly to criticise a local hospital trust, and for an hon. Member to do that, as in this case, shows enormous courage. Does she agree that the biggest mistake the Government could make when they publish and respond to the Ockenden review would be to say that this is a one-off incident? The most important thing is to consider what went wrong at Shrewsbury and Telford, and to learn those lessons for the whole NHS. The big thing that we learned from Morecambe Bay and Mid Staffs was that such lessons apply across the system.
Lucy Allan
My right hon. Friend makes an important point—I was going to come to it in my speech, so I will bring it in now. The Morecambe Bay inquiry was led by Dr Bill Kirkup, who said of the recent findings at Shrewsbury and Telford Hospital NHS Trust that
“two clinical organisational failures are not two one offs”,
and that that points to an “underlying systemic problem” that may exist in other hospitals. My right hon. Friend is right to make that point, and I thank him for his kind comments.
The interim findings in the Ockenden review were not published, and I understand that the hospital trust has not been told about them. The families were certainly not told about them, and neither were MPs. There has been no statement to the House, and we do not know what action is being taken to ensure the safety of women and babies at Shrewsbury and Telford Hospital NHS Trust.
Jim Shannon (Strangford) (DUP)
I am an avid watcher of that Sunday night programme, “Call the Midwife”—I am not sure whether you watch it, Mr Speaker—where everything seems to work out at the end of the day. The hon. Lady is outlining something that does not work out at the end of the day. She mentioned families. Does she agree that the care of mother and baby must be a priority, and that more support for mothers who have had several children must be considered, to ensure that they are coping and not expected simply to carry on because they already know what to expect? Every life is precious and adds more pressures to families, particularly mothers.
Lucy Allan
I very much appreciate the hon. Gentleman’s intervention. As always, he makes an excellent point, and I am grateful to him for his many interventions in many debates I have secured.
I am concerned that the NHS can choose to sit on this information, and that Ministers can say, “Well, we don’t comment on leaks”. This is about the safety of women and babies, and the adequacy of the maternity care they receive in our hospitals today. Women were repeatedly told that their case was a one-off tragedy, that there will always be risks to childbirth, and that such risks cannot be completely mitigated. Failings seem somehow to have been normalised, and at the time many women accepted that, rather than question or challenge the care they received. People trust the medical profession, which is why openness and transparency are so crucial.
When people raised concerns they were dismissed as being difficult—no one listened. There was a “we know best” attitude, and complaints about poor practice were treated as women making a fuss about a perfectly natural event that occasionally would have a negative outcome. As Health Secretary, my right hon. Friend spoke about “never events”, and I suggest that those must include an avoidable death. A baby dying in childbirth should therefore be a “never event”, yet it seems that that is not the way the deaths in this case were treated—they were treated as something that could be a result of childbirth. The trust even boasted of having the lowest number of caesarean deliveries in the country, so there seems to have been an unwillingness to intervene when there were complications in a delivery. In my view, an intervention during a difficult birth must be a good thing: that is what the clinicians and medical professionals are there to do. I am concerned about the way this trust appears to have treated women and about its attitude towards women, which seems to have been dismissive. And that is something we have seen from the top.
What adds insult to injury in this particular case is that the trust commissioned a report in 2013 that appeared to find that all was well. We now know, because of the leaked report, that that was in fact a whitewash. The trust was exonerated by what was a perfunctory bare minimum desk-top review. This allowed poor practice to continue unchecked. If it had been identified at the time, the more recent cases of malpractice, which are still coming forward and include death and injury, could have been avoided. We still do not know how many women and babies have been affected, but we do know that £50 million in compensation has been paid out already. However, with hundreds more women coming forward, the cases in which a financial settlement has already been reached are clearly the tip of the iceberg.
The question we have to ask, and must go on asking, is whether that poor care, and the normalisation and denial of it, is a systemic problem within the complex bureaucracy that is the NHS.
Lucy Allan
I shall be delighted to give way to my right hon. Friend and constituency neighbour.
Mr Paterson
I congratulate my hon. Friend on bringing this very, very difficult subject forward. I also thank my right hon. Friend the Member for South West Surrey (Jeremy Hunt) for launching the Ockenden review. It is very easy to talk about numbers, but every one of these cases is unutterably terrible and ghastly for the family concerned, and obviously a total tragedy. We all know dreadful stories from the past. The latest figures show that the infant mortality rate at Shrewsbury and Telford Hospital Trust is 3.7 per 1,000, against a national average of 3.9 and a national target, which I would like the Minister to comment on, of 2.6 by 2025. My hon. Friend has rightly raised the absolute horrors and the dreadful culture—we all know terrible stories—but does she derive any satisfaction from the fact that we are marginally better than the national average at the moment and possibly heading towards the national target by 2025?
Lucy Allan
My right hon. Friend makes a very important point. Clearly, the majority of women using these services have an excellent and safe experience. It is good news that there is progress and improvement, but we should not gloss over any of these cases. Regrettably, there have been new, recent cases in my constituency where women have come forward, having been made aware of the review, saying, “This happened to me a couple of years ago.” It is good that the numbers are improving, but we must make sure that every one of those deaths is treated as another event.
Philip Dunne
I am most grateful to my hon. Friend. I completely agree with my constituency neighbour, my right hon. Friend the Member for North Shropshire (Mr Paterson), that she is making a powerful case. It is quite right that she has brought this issue forward. On the subject of current practice versus some of the cases that are being considered in the Ockenden review, which stretches back 40 years, she will remember that it was initiated by the case of a couple who were constituents of mine. They lost their baby in 2009, over 10 years ago. Their concern was that, as my hon. Friend rightly identifies, the case had been inadequately handled and effectively covered up by the hospital.
One of my concerns, in addition to getting to the bottom of what has happened over a long period of time, is that we need to be reassured, as local Members of Parliament serving our constituents today, that the maternity services available to people in Shropshire are safe and of high quality. It would be helpful if in some way, given the scale of the inquiry that Ockenden is undertaking, there could be some interim finding on the current state of practice in Shropshire and Telford, so that at least expectant mums who are going to use those services can feel reassured. That would not prevent a more detailed inquiry going back into past practice. Does she agree with me on that point?
Lucy Allan
My right hon. Friend makes an excellent point. That might be something that the Minister can address, because we want users of maternity services to have absolute confidence in the care that they receive. However, we do not create confidence by hiding facts. If we can get some of the facts out that have been leaked to the media, let us do that and deal with those. He is absolutely right that that will help to reassure parents and give them confidence in the services that are being delivered—the vast majority receive a very good standard of care, and safe care.
The trust, and possibly other trusts, must work towards a culture of openness and transparency and perhaps show more of a willingness to accept that, “This can happen here.” I kept hearing, “Well, this can’t happen here. It hasn’t happened here,” and I cannot feel comfortable if people cannot acknowledge where things have gone wrong.
I recognise that the Minister may not have all the answers today, and I do not expect all the points to be addressed, but we need to know why NHS Improvement sat on the review’s findings for almost a year. Given how serious they are, why has it not come forward to say, “This is what the Ockenden review has found at an interim stage”?
I want to ask who knew what and when. Were Ministers informed, or were they too kept in the dark? If this had not been leaked, when would we have been told? When will the review be completed? It has now been almost three years. When will the Secretary of State make a statement on this very, very serious issue? I also want to know whether the management still think that this has been cooked up by the media, or whether they genuinely now realise that there is a serious problem to be addressed. It is very important that the Department of Health and Social Care and NHS bodies understand and acknowledge the seriousness, and that all parties are encouraged to be open about it.
As a constituency MP who has had women contact me recently to share their birth experiences at the trust, it seems to me that red lights are flashing. We need to know what is being done to ensure the safety of women and their babies using this service. I very much thank the Minister for her forthcoming comments and any reassurances that she can give my constituents on this issue.
The Parliamentary Under-Secretary of State for Health and Social Care (Ms Nadine Dorries)
It is an absolute honour and a delight to be responding to this debate with you in the Chair, Mr Speaker—it is the first time I have done so—and congratulations.
I congratulate my hon. Friend the Member for Telford (Lucy Allan) on securing the debate. Before I respond to her specific comments, I turn to the wider points that she raised that addressed the UK as a whole.
To reassure people—mothers, particularly—I would like to make one or two points about the wider context of the debate: the safety of giving birth in the UK. The NHS in this country remains one of the safest places in the world to have a baby. The Government’s maternity ambition is to halve the 2010 rates of stillbirths, neonatal and maternal deaths, and brain injuries in babies occurring during or soon after birth, by 2025. That ambition also includes reducing the rates of pre-term births from 8% to 6%. I reassure her that we have already achieved our ambition for a 20% decrease in stillbirths by 2020, so we are very much on track with those ambitions.
First and foremost, I express my heartfelt sympathies to every family who has been affected by previous failings in the trust’s maternity services. There can be no greater pain for a parent than to lose a child.
I pay tribute to my right hon. Friend the Member for South West Surrey (Jeremy Hunt), the former Secretary of State, who asked NHS Improvement to commission the independent review of maternity services at Shrewsbury and Telford in 2017, which is two years ago now—my hon. Friend was quite right about that. I take mild issue with one of her points, however, which was that NHS Improvement kept quiet about the failings. I find that slightly disappointing, because the raison d’être of NHS Improvement, which was also established by my right hon. Friend, is to investigate, expose and learn from failings, so I think she would agree it is not something that NHS Improvement would do. It is not in the culture of the organisation; the exact opposite is true.
The review being chaired by Donna Ockenden, a clinical expert in maternity and a registered midwife, was tasked with assessing the quality of previous investigations and the implementation of recommendations at the trust relating to new-born, infant and maternal harm. The original terms of reference covered the handling of 23 cases. The terms of reference have since been updated and were published in November to reflect the expanded scope of the review, and the review team will be in touch in the following weeks with the affected families to ensure that they are appropriately supported throughout the process. I am afraid I have to inform my hon. Friend and the House that the additional cases have now been identified and the total number relevant to the review now stands at 900, a small number of which go back 40 years.
The extra cases have been found by a number of means—from looking at previous incidents reported at the hospital to parents brave enough to come forward and talk about their own experiences. I am sure my hon. Friend will understand that, unlike with Morecambe Bay, which involved a small number of cases, it will take the review considerably longer to investigate 900 cases[Official Report, 20 January 2020, Vol. 670, c. 1MC.]. That is why there has been no report so far. The interim finding was not 600; the number is greater. It is appropriate that, while this important work is being done, we do not influence or comment on it and that we let Donna Ockenden get on with her vital work. It is our responsibility to let her do that and to provide the additional support needed given the additional cases identified. It is a huge increase on the original number of cases.
Jeremy Hunt
I thank the Minister for her personal commitment to patient safety, which I have seen on many occasions, but she will be aware that what she has just told the House is deeply shocking. She is saying that the scale of potential avoidable death at Shrewsbury and Telford may be no different from that at Mid Staffs. Could she reassure the House, given the huge resources devoted to the public inquiry into what happened at Mid Staffs, that the Department will make sure that Donna Ockenden has all the resources and support she needs, because getting to the bottom of this will be a huge job? Does the Minister also recognise that, while it will take more time, the families would also like it resolved as quickly as possible?
Ms Dorries
Absolutely, and I thank my right hon. Friend for his comments. Yes, the Department is liaising closely with Donna Ockenden about what support she needs to conclude her work as soon as possible, for the sake of the families. As he will understand, the review cannot be rushed; it has to be done properly and thoroughly. We have to get to the bottom of this matter, which is why Donna Ockenden is being supported in the way she is. Anything she needs in order to conclude this review successfully she will have. I thank my right hon. Friend for his personal comments. As he will know, and as he has said, I am utterly committed to patient safety, to eradicating avoidable harms and to making the NHS the safest place—not one of the safest—in the world to give birth. The review is important in the light of that.
As well as the families who came forward when the review was launched, media coverage has raised awareness of it, prompting further contacts with the trust and the review team. More recently, Donna Ockenden herself made a final appeal for any more families who believe that they have been affected to come forward. I am grateful to all the families who have voluntarily agreed to assist the review, although that may mean their having to revisit painful and distressing experiences. We expect it to conclude by the end of the year, at which point the Government will work closely with NHS England and NHS Improvement to consider the next steps.
As I have said, it is important for the review to be allowed to proceed unhindered, and without speculation about its conclusions or findings. However, I am very aware that current maternity patients at the trust may want reassurance that they will be safe and looked after. My hon. Friend the Member for Telford referred to “red lights”. I can reassure her that steps are being taken at the trust. It is completely understandable that people are asking questions, but I have asked for a meeting with the interim chief executive, because I want to see for myself that those steps are working. She has already made a public statement to reassure all families using the trust’s maternity services that much work has already been done to address issues raised by previous cases and to improve services, while acknowledging that the trust—obviously—had further to go.
During the November inspection of the trust’s maternity services, the Care Quality Commission found that the trust had taken action following the last inspection in April, so it was clearly listening and implementing the recommendations. As a result, there had been a number of improvements. Although more work was still needed, staffing had increased, and morale and governance had improved. However, I expect the CQC to keep a close eye on what is going on.
Let me end by restating the strength of our commitment to improving the quality and safety of maternity care. As I have said, the Government’s maternity ambition is to halve the 2010 rates of stillbirth, and we are on track to do that, which is incredibly important. Let me also say to my hon. Friend that, although I cannot reveal to her what is happening in the review—I cannot find out what is happening myself, because Donna Ockenden needs that autonomy—my door is always open. If my hon. Friend wants to discuss with me at any time what I have said tonight about the improvements that are being made at the trust, she need only pick up the phone. I am there to answer any questions that she may have on behalf of her constituents, and I ask her please not to hesitate to contact me if she needs further reassurances.
As I have said, the NHS remains one of the safest places, although we want to make it the safest place. What is most important is to ensure that the tragic cases that the Ockenden review is examining are not repeated anywhere else. That must be the objective. Women deserve a better maternity experience, and that is what we are determined to achieve.
Question put and agreed to.