Preventable Baby Loss

Wednesday 4th September 2024 Westminster Hall

09:30

[Lee Anderson (Ashfield) (Reform)]

I beg to move,

That this House has considered preventable baby deaths.

It is a pleasure to serve under your chairmanship today, Mr Dowd. This debate is not the type of debate I look forward to because it is filled with sadness and sorrow. I am delighted to be joined by some of the Ashfield families who have been affected by baby loss in the past couple of years or so. According to the Royal College of Midwives, every day in the UK 1,845 babies are born alive and there are between 302 and 428 miscarriages. We have eight stillbirths per day with 145 babies born prematurely and five neonatal deaths.

When a pregnancy is announced in the family, on most occasions it is a joyous, wondrous time in people’s lives. They are happy. Dads make plans for their son to be a footballer—they have picked the football team already. Mums look at princess dresses, even though the baby is about as big as your thumb. Grandparents squabble over who will have rights to look after the new grandchild. There are all sorts of plans such as what schools they will go to. Especially for first-time mothers it is a strange time—a wondrous, joyful time—and once things settle down would-be parents sometimes get a little bit apprehensive and scared, worried about the baby and whether he is going to be well. Will he be born well? Will he develop properly? It turns from being happy to being concerned, but still happy.

There are quite a few risks, as we know, in pregnancy, during birth and in the postnatal period. Every preventable stillbirth, neonatal death or infant death of a child is a tragedy and we must make all efforts to prevent it happening. The families that I have brought here today believe, along with the hospital, that deaths were preventable. Mistakes were made and things were missed. I hope that today the ministerial team can give the families something so that they can go away and know that they have been listened to.

There are factors apart from mistakes, such as diabetes, obesity, drinking too much, smoking and other factors in pregnancy that can affect how a baby develops and ultimately how healthy it is once it is born. But as I say, in these cases mistakes were made. I have spoken to some of the families, and two families are here today. I will read out their stories—not my words, but their words. I asked them to print out their stories so that I could read them out here in Westminster Hall.

The first one is from Rob and Emma Stretton. They tell the story of Olivia. This is from Rob:

“On the 31st of May 2023, Emma and I attended a routine scan at King’s Mill Hospital, Mansfield. During the scan a few issues arose. The sonographer called for assistance from her senior and her recommendation was made to contact a consultant. His decision was that Emma needed admitting immediately for observation. The time was approximately 14:30. We were taken upstairs to the maternity unit where the situation was explained to a midwife at the nurse’s station. Her reply was we should return later as no beds were available and a phone call should have been made to the ward prior to attending. The consultant suggested for us to return in a couple of hours to which the midwife replied this wouldn’t be feasible due to shift change over. She said between 19:30-20:00 would be better.

After this we left for home and returned to the ward around 19:45. Emma was admitted for monitoring and once she was settled, I returned home. Upon entering the house, I received a phone call from a midwife advising me to return as soon as possible as no foetal heartbeat could be obtained. I went straight back to the ward to be informed our baby…had died. Emma was given medication to induce labour and gave birth to our stillborn daughter three days later at 18:13.”

The next story is from Bianca Chapman. This is Imiza’s story:

“My placenta was completely covering my cervix. I was a high risk pregnancy. I had a bleed in the November and wasn’t given much advice on any risks. In the early hours of 3/12/22 I had a big bleed and went into KMH. The registrar raised concerns but was ignored by the consultant. In the space of just over 24 hours I then had several more bleeds. It wasn’t until my daughter’s heartbeat baseline stopped beating I was considered to be allowed surgery.

The consultant in charge had gone missing, which delayed my daughter coming out. The ward was on code red. It took 45 minutes to find him. I was then operated on to find out my placenta had abrupted inside me. They struggled to get my daughter out so they had to make a further cut in my stomach, which now due to that I will never be able to give birth naturally.

My daughter came out at 11.16 am not breathing. It took 7 minutes to resuscitate her. I had clumps of placenta floating around my stomach and had to be put to sleep to have further surgery. We were led to believe she was fine, but we weren’t able to see her. We were told they was just waiting for her to urinate. She was later transferred to LRI, which was when we were finally told the truth: she had a bleed on her brain due to being left inside me too long with no oxygen. Her nappy was filling with blood.

Within the space of a few hours, we were told she would be highly disabled, to get your family here, who you would like to meet her, as it’s in her best interest we turn her life support machine off. After turning her life support machine off I was then told I was going to be put back on the maternity ward around all mothers and babies…There was no way in this world I wanted to be around alive babies.

Once we had our investigation, we were told a lot of things that could have prevented all of this. We was told if she was taken out around 7 am she would be alive right now. Those vital few hours made all the difference yet we was left to suffer a lifetime of pain through a choice of a fully qualified consultant…We were also told he would of known her life expectancy would be short due to the abruption yet he told us she would be home with us for Christmas and not to worry.

We believed in them to be later proved it was all a lie. All that happened to the consultant responsible for our baby girl’s death was he was audited. We are now both changed forever…I was pushed out in a wheelchair holding a memory box as that’s all my daughter then was, a memory.”

Amelia Bradley wants to tell Theo’s story:

“My pregnancy was the typical normal pregnancy. I attended all antenatal appointments and was deemed as low risk. On the 13th September 2023, I attended King’s Mill Hospital in the evening, despite being a booked homebirth, to get some pain relief. On the first admission to the Sherwood Birthing Unit, I was left waiting for 40 minutes, before being told by a supporting midwife that they were really busy, and someone would see me shortly. 30 minutes later, the same midwife returned to complete my original triage assessment, something that should be undertaken within 15 minutes of arrival.

This midwife apologised for the delays and started my assessment immediately when she came back into the room. She told me that I was l to 2 cm dilated and that my cervix still had some changes to make until I was in active labour. She still deemed me as low risk, gave me a codeine tablet and said that I would still be suitable for a homebirth, as the only pain relief I could get with a water birth would be gas and air.

I got home at around about midnight and got into my birthing pool, before leaving it to use the toilet at around 12:30 on the 14th September. I had 2 contractions on the toilet and felt a pop, which was followed by bleeding. I put on a pad to monitor the bleeding and within 2 to 3 minutes, it was full. Luke rang the Birthing Unit and put the phone on speaker so I could consent to them talking to Luke and my mum because of how much pain I was in, and I couldn’t speak for myself.

They asked if I had lost more than a teaspoon of blood, to which my mum said ‘Yes, it’s like a heavy period, but pure blood.’ The midwife didn’t ask any questions about the pain I was in and didn’t try to gather further information on the amount of blood loss. She told me to come back to the hospital.

We returned to the hospital just before 1 am and on getting to the ward at 01:04, I was put into a triage room. 10 minutes later, a support worker came to take my observations, but ignored my mum when she tried to show her the blood-filled pad, and then failed to alert any of the midwives that I was bleeding.

After being in the room for 37 minutes, while 2 triage midwives, a labour ward co-ordinator and several other staff were sat around their nursing station discussing how many Haribos they’d eaten on the shift, and how other midwives who were on bank shifts were getting paid more…a midwife”

never entered the room. When one did enter, she

“took a look at the pad and her face dropped, noting the seriousness of my condition. She couldn’t find Theo’s heart rate, so went to get support and a Doppler to see if this could pick the heart rate up. She found him to be bradycardic and issued a 2222 emergency. The consultant came and ordered for a category 1 C-section to take place.”

The baby died.

This is the story of Hayley Moore:

“My story…Had previous placenta eruption in 2021, was very lucky—was picked up and I was straight down to theatre for an emergency C-section. This time around I was very anxious about it happening again, was questioning the consultant. He said I was only under him because small baby last time. I wanted a planned C-section, but he kept pushing me to go natural and full term.

I went in on the 17th of February with reduced movements and pains, was hooked up to the monitor, was told I can’t be having contractions so was sent home. On the 19th, went for a scan. I felt it was rushed, still said I don’t feel right. They said baby had grown and looked fine. Felt movement early hours.

The next morning by 10 am on the 20th I was at home in agony, rang the birthing unit, they told me to go down so I did. Got there, was sent into assessment unit. Midwife came, checked for heartbeat…had to wait for scan…then moved down to room 11, where the bereavement midwife came up. The doctor was pushing me to go natural again as I was stable.

The midwife at the time, along with my sister, was pushing for my C-section…in the end, I did get rushed down for a C-section, and again my placenta had erupted. The aftercare I received from midwife Holly…was outstanding.”

That is four stories.

Recently, I visited King’s Mill hospital and the maternity unit, where I managed to walk around with the chief nurse, Mr Phil Bolton. It is a brilliant facility at that hospital. The problem that hospitals have, however, is the headlines in the newspapers, which are always bad. We never see the front page of a local paper saying, “Hospital saves a life”, although that is what they do every single day.

Mistakes have been made, and individuals have made mistakes, but I also have to say that I am incredibly proud of King’s Mill hospital, which is where I was born and where my children were born, and it is probably the place where I will leave this earth, when I eventually go—though I have no plans to do that just yet. It is a brilliant hospital, but mistakes have been made. But King’s Mill hospital acknowledged the mistakes; it put measures in place and learnt from some of the heart- breaking stories we have heard today.

I am not here to talk about King’s Mill hospital; I am here to talk about my constituents, who have suffered the most horrendous grief. Baby loss will always happen—we know that—but those were preventable deaths. We must do all we can in this place to ensure that our national health service has the support it needs to make sure that we reduce baby loss.

We know about the Ockenden report in Nottingham. Some of the news coming out of that is quite shocking. I fear that we sometimes treat the birth of babies like a production line—it is not. It is very personal and emotive. Every single family is completely different; mums and dads are different. If we can learn anything from today’s debate, it is that from the families I have spoken to, baby loss touches every single family in this country. Somebody along the line will know or be related to somebody who has had baby loss, whether that be a miscarriage or during childbirth or post-natal.

I ask the ministerial team to have a look at my constituents here in the room today. I know it is not always possible to empathise, because we have not all been through the same thing, but please reassure them that they have been listened to. I cannot go any higher than this. We have the complaints in and the solicitors involved. As a Member of Parliament, all I can do is listen to my constituents and their stories, bring them to this place, let them see the people running this country, and ensure that their stories are listened to and that the facts I have given today are acted upon.

[Several hon. Members rose—]

[Peter Dowd (in the Chair)]

I remind Members that if they wish to speak, they should bob—as some of you have done. Thank you for that.

09:46

[Nigel Farage (Clacton) (Reform)]

My hon. Friend the Member for Ashfield (Lee Anderson) has raised a subject that is, for many families and communities, a taboo. It is very, very difficult to talk about. When it comes to prevention, he is quite right to pay tribute to the hospitals where every week, thousands of healthy babies are born. Where there have been errors—we have seen it not just in Nottingham; one of the Kent hospitals had a particular problem with this—everything should be done to make sure these deaths are prevented. Whatever we do, however, naturally some stillbirths will still happen.

I have seen the effect of stillbirth in my own family. It is pretty devastating. It does not go away or get forgotten. Are those that go through this, particularly the women, able to talk about it? Can they share their experiences? A problem shared may not be a problem solved, but it might just make life a little bit more bearable—a little bit easier. I must be honest: when my niece had that stillbirth, I did not feel I could face her and talk about it. I felt too awkward. Would I say something that was wrong? Was it best we just did not discuss the subject? A decade on, even though I am close to her, I have never discussed it. I have just felt too awkward to do it. I suspect that is the case with many men, including husbands and partners. It is just something that is not talked about.

I want to pay tribute to councillor Jeff Bray, the former leader of Tendring district council, who has talked about the stillbirth experience as a father. I am also encouraged by Maria Gormley’s charity in Clacton, where women—and men if they want to—can come together regularly and share their experiences. It is not an easy thing to do. I have admitted my own failings, but I suspect I am far from alone in finding this subject incredibly difficult.

As my hon. Friend the Member for Ashfield said, anything that can be done to prevent avoidable disasters must be, but I want to put it on the record that naturally, these things will happen—hopefully in very low numbers. There needs to be counselling and support for people who have been through that experience. To be honest, I feel that in most parts of the country, it is very sadly lacking.

09:49

[Lizzi Collinge (Morecambe and Lunesdale) (Lab)]

I thank the hon. Member for Ashfield (Lee Anderson). As a woman who has lost two very much wanted pregnancies, baby and pregnancy loss is very close to my heart. I also represent an area that, in the past, has seen poor maternity care cause the death of babies. I want to speak about the importance of local support for parents and families, and to give those support organisations a voice here in Parliament. I also want to highlight the absolute necessity of rigorous investigations and true candour when babies die. My constituency hosts two excellent support groups for people affected by pregnancy and baby loss: Matilda’s Mission, set up by Chelsie and Matt after the death of their baby Matilda, and the Tigerlily Trust, set up by Val in memory of her daughter Lily.

Matilda’s Mission and the Tigerlily Trust work with local bereaved families. They provide a whole host of support, including remembrance boxes for bereaved parents to make and collect as many memories as possible in the short time they have with their babies, and to give them resources when they return home. There are sibling memory boxes for bereaved living siblings, sibling play sessions, and support groups, which in particular can combat the loneliness and isolation often felt with this sort of grief. They provide a place where people can come and heal together. There are dad drop-ins, one-to-one catch-ups, grandparent events, older sibling events, whole family events at holidays such as Christmas, and of course events around Mother’s and Father’s day. The two groups also work with hospitals and universities on maternity bereavement care and host Baby Loss Awareness Week events.

I asked Chelsie, Matt and Val what they wanted me to say today, and they told me that funding is an issue. For example, the bereavement suite at the Royal Lancaster infirmary, co-designed with bereaved parents, has been closed for some time due to safety concerns. While the trust continues to work on that, maternity bereavement does not seem high on the agenda when it comes to budgets. As Chelsie said in her beautifully blunt way, “Dead babies and their families matter too.” Funding for support groups is also extremely difficult, with some groups struggling to get support for funds to continue. Support for families is currently a postcode lottery, often involving lengthy referral times for NHS services or support from charities. When families are in the depths of grief, 12 weeks’ wait for a referral is tough going. Families need consistent and timely care.

Matt, Chelsie and Val also wanted me to mention bereaved dads and non-birthing parents. The lack of support again is apparent, and their role can often be seen as merely supportive to the mother or birthing parent, rather than as a grieving parent themselves. Something important to me—this was mentioned by the hon. Member for Ashfield—is tackling the idea that natural childbirth is somehow superior to medically assisted childbirth. At its worst, that belief—and it is no more than a belief—has killed babies.

Finally, I want to mention something that touches all aspects of health and social care, and that I am sure our new Government will take very seriously. When things go wrong, it is the duty of all organisations involved to be fully truthful, transparent and willing to learn. When adverse outcomes are potentially due to failures in care, too often families experience insufficient and prolonged investigations that add to the trauma. We owe it to the babies lost—baby Matilda, baby Lily, baby Theo, baby Olivia, the baby daughter lost to placental abruption and Hayley’s baby—not only to find out what happened to them, but to ensure that we prevent every single future death we possibly can through a rigorous commitment to investigations at pace, a culture of safety, and the best possible patient care.

09:54

[Jim Shannon (Strangford) (DUP)]

It is a pleasure to follow the hon. Member for Morecambe and Lunesdale (Lizzi Collinge) and to hear her contribution as well. In particular, I thank the hon. Member for Ashfield (Lee Anderson) for setting the scene, as he often does, with a passion and an understanding of his constituents that we all see, and for describing the examples of his constituents who have suffered in this way. He did it with sensitivity, because it is a very sensitive debate. As a father and a grandfather, my thoughts are with those who have faced and are living through baby loss; there are many who have. I say “living through” because I know that it is not something to get over as such.

I could give many examples, but I will give just one. The hon. Member for Ashfield said that every family has been touched, and he was right. My mother has had a number of miscarriages, as has my sister and Naomi in my office, so the issue of baby loss resonates with us all.

There was a lady I greatly admired. Her name was Agnes Thomas. She is dead and gone, but she was 4-foot-nothing. There wasn’t much of her, but she was definitely a whirlwind. I remember her coming to see me. She took care of her 105-year-old mother—and that is the age her mother was when she passed away. Agnes had a very ill husband, and she had minimal help from anyone. Within a few months of her passing away, her mother and her husband died too. She was the centre of that home and one of the strongest women that I have ever known—apart from my own mother, of course, who at 93 is equally strong. However, underneath all that undeniable strength was also a lady that, in her 80s, came to the office to see whether she could find out where her stillborn son—

[Helen Morgan (North Shropshire) (LD)]

The hon. Gentleman is making a powerful speech. It is good to hear the story of Agnes, and I hope that he will agree with me that sympathising with our constituents who have suffered such awful circumstances and telling their stories in Parliament is a good way to ensure that they are heard in the future.

[Jim Shannon]

I thank the hon. Lady for that. The story of Agnes’s son is this: her stillborn son was born sleeping in the early ’70s and was buried. Agnes came to see me over 50 years later.

[Lee Anderson]

The hon. Gentleman is making a very passionate speech, and I think everybody in Westminster Hall can tell how impassioned he is. He tells a very touching story. Does he agree that it does not matter how long ago baby loss occurred—it will always stay with the family?

[Jim Shannon]

I am sorry for being emotional. I know that I should not be. I thank the hon. Gentleman for giving me a chance to recover some of my composure.

Agnes came in tears to ask where the Royal Victoria hospital had buried her son. It meant something to her, even though it was 50 years later—that wee small lady, standing in my office telling me her story, which was breaking her heart 50 years later.

The loss of a baby is life-changing, and my thoughts are with those families who have been mentioned in this debate. There will be others. Other hon. Members will speak, and they will tell the same story with the very same emotion, compassion, understanding and that realness that the hon. Member for Ashfield compounded in such a fantastic way in his introduction.

The fact that baby loss can be preventable makes the outcome that bit more difficult to accept. Sands is a phenomenal charity, and it has given the following statistics. I always give a Northern Ireland perspective simply because I feel it adds to the debate, but it also tells us that the things happening here are no different for us back home. The stillbirth rate declined 17.7% in Northern Ireland between 2010 and 2022. However, comparing the rate over a three-year average shows a smaller reduction of 10.1%. My goodness! Though it is decreasing, it is still there with a vengeance. The neonatal mortality rate has been higher in Northern Ireland than in any other UK nation since 2013. It is equally bad wherever it is, but I am just making the point that Northern Ireland has examples of it that are above the rate anywhere else.

[Carla Lockhart (Upper Bann) (DUP)]

I thank my hon. Friend for his powerful speech. This is certainly a debate that resonates with me on a very personal level, but I want to make mention of a little boy called Teddy from my constituency of Upper Bann, who died from sudden infant death syndrome. He will be forever seven weeks old. Does my hon. Friend agree that we need better wraparound services, particularly in our hospitals, with rooms made available for families who find themselves in these most tragic circumstances? There should be support, counselling and help right through their grief journey.

[Jim Shannon]

I thank my hon. Friend and colleague for that intervention. What she says is absolutely true.

I tend to be emotional at the best of times, but whenever someone loses someone, particularly at that time, it resonates with everyone. It is a time when people want to wrap their arms around them, because it is the right thing to do. At the same time, there has to be someone outside. The hon. Member for Ashfield gave some examples where—with respect—people were just sent home when they needed someone. That is so sad. I feel that there should be a greater role for churches and ministers to help and, as best they can, to give succour and support physically, emotionally and mentally. Those are things that we have probably all tried to do.

Unlike stillbirths and neonatal deaths, the total number of miscarriages and miscarriage rates are not reported in Northern Ireland. That needs to change. It is a matter for us back home and not the Minister’s responsibility, because health is devolved, but I do feel that we need to do better. I still feel that the aims in the mainland should be replicated. I know that the Minister is sitting in for another Minister who cannot be here, but maybe it could be conveyed to the responsible Minister that we should look at an overall strategy for the whole United Kingdom of Great Britain and Northern Ireland.

Although there is an ambition in England to halve the 2010 rates of stillbirth, neonatal death, pre-term birth, maternal death and brain injury by 2025, there is no equivalent ambition in Northern Ireland. There really needs to be one; that is one thing that I would love to see. Sands states:

“The Northern Ireland Executive must commit to reducing pregnancy loss and baby deaths and eliminating inequalities. Any future targets must have a clear and agreed baseline to measure progress against.”

It is not just about having a goal; it is about having a goal that means something. With respect, we can have words until the cows come home, but they mean nothing unless they turn into action. Sands further states:

“These targets should be the driving force behind a programme of policy activity, with funding and resources to meet them.”

I agree. The ambition of this debate is to highlight the need for funding and resources, highlight the issue, make people aware and give an outlet to those who have suffered so painfully and who will carry that burden with them all their life. That is what I too am advocating, not simply for England but throughout the whole United Kingdom.

We have midwives who regularly find themselves staying after handover, as they are understaffed. We find exhausted junior doctors being left with full maternity wards while their SOs catch up on the never-ending paperwork. We have cleaning staff telling us that they do not have time to do all they need to clear rooms of infections. All those things are a matter of funding, and they are all UK-wide.

In all parts of this great nation, these are matters of life and death. The death of just one little baby that did not need to happen—we all have examples in mind today—is a tragedy. The number of babies who have died needlessly is not just a tragedy, but a catastrophe. We need to change it. With that in mind, I congratulate the hon. Member for Ashfield on giving us all an opportunity to participate in this debate in a small way, but with united force. Politics aside, we are here as MPs on behalf of our constituents, and we will all say the same thing: the loss of a baby is devastating to a family. If we can do something, we must. Let us support staff and, by doing so, support the health of our mothers and their children.

10:04

[Mrs Sharon Hodgson (Washington and Gateshead South) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Dowd. I thank the hon. Member for Ashfield (Lee Anderson) for securing this important debate and for his moving opening speech. My thanks also go to Bliss for the briefing that it provided.

This is an incredibly important debate for me and, I have no doubt, for all of us here today. As some Members will know, I—like many others here today, sadly—have experienced the devastation of baby loss. Having not spoken about my experience of baby loss until 2016, 11 years after I became an MP, I know how difficult this can be to talk about openly. I want to thank all colleagues for being here, some of whom have personal motivations, as we have heard.

I want to tell you a little bit about my daughter Lucy and about my experience of baby loss. My daughter Lucy was born at 23 and a half weeks, and sadly she was stillborn. Her heart beat throughout my labour until just minutes before she was born. The experience of giving birth to a stillborn child is incredibly traumatic, as we have heard and as I have spoken about previously. It feels weird that the world around you is not responding as it would if you had given birth to a live baby. I felt that I made everyone around me, or anyone I met, feel very uncomfortable: it is one of the last taboos, as the hon. Member for Clacton (Nigel Farage) spoke about. No one knows what to say to you when you have lost a baby or given birth to a stillborn baby—it is everyone’s worst nightmare—so I did not talk about it, and I certainly did not tell anyone new to my life who had not known me before I lost Lucy. When I became an MP in 2005, it took me until 2016 to actually talk about it in this place, or to anyone from my post-baby-loss life.

What compounded this grief was the fact that Lucy did not receive a birth or death certificate. Even more upsettingly, in my records it was not recorded as a stillbirth; it was recorded as a miscarriage. Because she was just days away from being 24 weeks, she was three or four days short of the required legal age to be eligible for a death certificate. Because of that, she does not officially exist in any official records other than our own family records.

We did name Lucy during a blessing in a private room, which I was moved to after she was born, when I had to give birth in the maternity ward among all the live babies. She was then taken to the chapel of rest and we held a very small funeral service for her, organised by the chaplain at the hospital and the Co-op, which funded everything. I will be forever grateful for that: it meant a lot at the time and still does. The acknowledgment of Lucy’s existence that they provided us with was truly invaluable, particularly when it had been denied to us by the lack of a death or a birth certificate.

After my experience, I knew things had to change, even though I could not talk about it for a long time. Alongside the former Members Will Quince, Antoinette Sandbach and Victoria Prentis—some of us here will remember Victoria, who left the House at the last election—I became one of the founding members of the all-party parliamentary group on baby loss in 2016. I am pleased that the APPG is still going; I hope it gets reformed. It has become a vehicle for making great progress with regard to baby loss, in particular for securing bereavement suites across the country, improved patient pathways and better recording of data, among many more improvements. Still more are needed, sadly.

I then became one of only two MPs on the pregnancy loss review, alongside our former colleague Tim Loughton, following his private Member’s Bill. The review’s work resulted in significant changes—not least the decision, announced just earlier this year, that parents who lose a baby before 24 weeks of pregnancy in England can now receive a certificate in recognition of their loss. I know that this has been a great source of comfort for many who now feel they can finally get a formal recognition and acknowledgment that their baby existed. I am certain that it would have made a huge difference to me and my family.

[Carla Lockhart]

I thank the hon. Member for the moving real-life story that she has told. I commend her and her colleagues for their efforts on baby loss certificates. Does she agree that a greater effort needs to be made in the devolved regions—I am thinking of Northern Ireland—to replicate what is happening here in England with baby loss certificates, such is the importance of the issue for families?

[Mrs Hodgson]

I absolutely agree. I only realised that the certificates were just for England when we were pulling together my remarks for today. That is remiss; I encourage the devolved nations to follow the example of England and bring the certificates in, because they really make a massive difference to parents suffering early baby loss.

Despite these improvements, we still have a long way to go to provide the care and respect that all families need during such a difficult time, as well as to ensure that we take steps to reduce stillbirth rates. As expressed by Bliss, an organisation that campaigns for change for babies born premature or sick, there has been a concerning increase in the neonatal mortality rate and the pre-term birth rate. It points to a high variation in care as a factor that can be addressed to reduce that worrying increase.

As the MP for Washington and Gateshead South in the north-east, I know just how damaging the impact of inequality can be as we experience the acute end of regional inequality, which can manifest itself through less investment and less access to the resources we need. In relation to baby loss, inequality prevails and, as Bliss highlights, the number of babies lost to mothers from the most deprived areas has increased at a rate twice that of babies lost to mothers living in the least deprived areas.

It would be remiss of me not to mention that neonatal mortality rates are much higher for babies from an ethnic minority. Babies of black ethnicity are twice as likely to be stillborn as babies of white ethnicity. It is a failure of our healthcare system that babies of black and Asian ethnicity continue to have much higher rates of neonatal mortality. Disgracefully, that disparity is also seen in maternal healthcare. Maternal mortality for black women is currently almost four times higher than for white women. As some Members may have heard, the tennis star Serena Williams has spoken in great detail about her awful experience in that regard. I encourage Members to read her article in Elle magazine, which is still available online. Even as a very wealthy and globally recognised figure, Serena’s voice was dismissed during pregnancy and childbirth.

We must ensure that there is the right training and support for healthcare professionals to ensure that all those terrible disparities are addressed. The cases that we have heard today are so traumatic. Crucially, we must centre the voices of patients—usually mothers, but sometimes their partners as well—and listen to what they are saying about their own bodies and experiences. As we have seen with the high level of disparity in neonatal healthcare outcomes, we will fail to achieve change if we are not listening to those at the heart of this crisis.

If we are to effect change, we must also increase our midwifery workforce, as well as increasing the capacity in our NHS to allow the necessary training to be delivered. I am pleased that Labour is taking strong action to get our NHS back on its feet. In our manifesto, we committed to training thousands more midwives as part of the NHS workforce plan. It is also significant that Labour has said that we will ensure that trusts failing on maternity care are robustly supported into rapid improvement, and we will set an explicit target to close the black and Asian maternal mortality gap.

[Mr Gregory Campbell (East Londonderry) (DUP)]

Does the hon. Member agree that two points that have emerged from this important debate are that greater resources are required to deal with the problem, and that a greater understanding is needed of the individualistic nature of the problem? No two mothers or families will react to baby loss in exactly the same way, as she and other hon. Members have so passionately outlined. Those are two of the most important issues arising from the debate, and hopefully we can learn from them.

[Mrs Hodgson]

I absolutely agree. The hon. Member makes a very valuable point: resources matter, but it is also about how they are implemented. Human interaction and professional training is so important.

I am hopeful for the future and proud of the change that has been made so far. Looking at all colleagues in the Chamber today, I know that together we are a powerful voice that can make such a difference to families during that terrible time and can help to improve outcomes for others, so that fewer people experience this most dreadful loss in future.

10:15

[Andy MacNae (Rossendale and Darwen) (Lab)]

I thank the hon. Member for Ashfield (Lee Anderson) for securing this important debate, and the families for being in the Public Gallery and sharing their experiences. I speak as the father of a daughter called Mallorie, who we lost at five days, so I share their experiences.

We have heard some stark statistics, and I will seek to summarise the national picture and some of the measures that we might be able to take. We have heard about the number of losses, and that every loss is a personal tragedy. We have also heard that every loss is not inevitable. Up to one in five stillbirths and neonatal deaths are preventable. In 2015, the then Government announced an ambition to halve the rate of stillbirths and neonatal deaths by 2025 but, sadly, progress on delivering on that ambition has stalled. Without renewed action we are going to fall well short.

To dig a bit deeper, as my hon. Friend the Member for Washington and Gateshead South (Mrs Hodgson) highlighted, there are still further causes for concern. According to the 2022 perinatal mortality report, black babies are more than twice as likely to be stillborn as white babies, and black and Asian babies are more than 50% more likely to die shortly after birth compared with white babies. Research by baby loss charity Sands has explored the reasons for that inequality, and as a result is calling for specific actions to deliver positive, joined-up, empathetic maternity and neonatal care, through its End Inequality In Baby Loss campaign. I urge our new Government to support those actions.

Baby loss charities are highlighting wider areas where improvements could help to prevent baby loss, including greater consistency in ensuring that maternity services meet nationally agreed standards and guidelines. In effect, we know what needs to be done but we need to implement it, particularly in respect of the NHS saving babies’ lives care bundle. Linked to that is the need for maternity units to be properly staffed, as we have heard so many times today. The Sands and Tommy’s joint policy unit estimates that nearly a third of neonatal intensive care unit shifts are not properly staffed. In addition, 63% of midwives have felt unwell in the last 12 months due to stress. Overall, in 2022-23 nearly half of maternity services were rated as “inadequate” or “requires improvement” by the Care Quality Commission.

We know that the NHS as a whole has been left broken by 14 years of neglect, and now we must look to our new Government to ensure a safe maternity care system in which national guidelines are consistently followed. But sadly, even with the best care and support, many families will still suffer the pain of baby loss. Effective bereavement support can be crucial in helping families to come to terms with their loss. Again, I speak from personal experience in that regard.

Despite wonderful work done by charities—I want to mention the Friends of Serenity in my area of Rossendale and Darwen in Burnley—and by NHS trusts, far too many bereaved parents cannot access the compassionate care that they need. That can hugely impact their wellbeing in the short term and for the rest of their lives. Of course, this has related social and economic costs. As with so many aspects of primary care, effective early support reduces demand in the longer term. The issues and solutions are well understood.

Healthcare professionals across the UK do not have sufficient access to bereavement care training, which means they are not adequately supported to gain the skills and confidence they need to provide excellent care for families when a baby dies—or, indeed, to look after their own wellbeing. The national bereavement care pathway provides nine standards of care across five different experiences of pregnancy and baby loss to ensure equality of bereavement care no matter where a parent lives in the UK. In England, all 128 NHS trusts have now signed up to the NBCP standards. I hope the new Government will consider making the pathway mandatory and providing the funding to help trusts to implement the standards.

I will finish off with a reminder that Baby Loss Awareness Week is coming up in October, culminating in the global wave of light on 15 October. I hope that fellow Members can support the events in their constituencies.

10:20

[Olivia Blake (Sheffield Hallam) (Lab)]

It is a pleasure to serve under your chairship, Mr Dowd. I thank the hon. Member for Ashfield (Lee Anderson) for securing this important debate. My thoughts are with all the families whose experiences he shared today and with all those present who have shared their personal experiences.

This is an issue that is deeply personal to me, and I have spoken about it many times in the last five years. I am sad to say that I have not yet had my rainbow baby, but that does not stop the questions every single month for probably the last year, asking whether I am pregnant. I encourage colleagues not to ask women, because not only is it very rude but it can cause a lot of heartache for those who are struggling to conceive.

I have had the honour of working with dedicated campaigners, including Myleene Klass, and we were privileged to welcome the then Minister responsible for women’s health to Tommy’s at Birmingham Women’s hospital. It was great to get them there. I extend that same invitation to the new Government’s health team to see the research that has been done there; to see an alternative model of care, which would see the end of the three-miscarriage rule and has since been piloted in response to the review; and to meet the families who Tommy’s has helped to have their rainbow children. It was incredibly rewarding to hear their stories about how small changes in care can really make that difference and allow people to have the families they so desperately need, while remembering the children they were unable to hold in good health. It has been brilliant to work with Tommy’s and Sands for several years, pushing for meaningful and long-overdue changes.

It is estimated that 50% of people will be affected by baby loss during their lifetime, either personally or through someone they know. Miscarriage is common but that does not make it any less heartbreaking, and often that leads women—as well as men who have gone through it—to face grief in isolation. We have been trying hard to break the taboo, increase support from employers and establish bereavement leave and better mental health support, because in many cases there is none. Most importantly, we have been trying to improve the pathway of care by pushing for more early intervention for women who may be at higher risk—such as myself as I had undiagnosed diabetes—and for funding for research to make sure we are doing all we can to improve the life chances of people going through pregnancy.

In the UK, 13 babies tragically die before, during or shortly after birth every single day. National reports indicate that up to one in five of those stillbirths and neonatal deaths could be prevented if guidelines were simply consistently followed. That is not good enough, and those deaths are not mere statistics but heartbreaking losses that call for our immediate attention and action.

I want to highlight the progress being made in addressing the challenges in miscarriage in response to the independent pregnancy review, because it is important that we show that more can be done. We have touched on the three-miscarriage rule; it is important that we make sure that ending that is rolled out successfully. We are waiting for the results of the pilot, but I hope the Government will take seriously that change in the model of care, which is backed up by research.

By all accounts, the number three was picked out of mid-air, and there is no reason why someone should have to wait to have three miscarriages before they get basic tests for diabetes or for other reasons to understand why they may have miscarried. It is cruel—we would not expect anyone to have three heart attacks before doing a basic test—and it lays bare the sexism in our medical system that we would allow people to go through that so many times and face so much loss and trauma before giving them the answers they need to perhaps go on to have successful pregnancies.

The review provided 73 recommendations across various areas, including the graded model of care, which would be the alternative to the three-miscarriage rule and would give people the support they need after one miscarriage. It is currently being trialled at Birmingham.

Another vital recommendation is 24/7 access to miscarriage care. At the moment, people may or may not have access to an early pregnancy unit, depending on where they live in the country. They may not have any access to information about what to do if they are suffering a miscarriage, which leads to people turning up to A&E or staying at home and losing a child unnecessarily. This critical measure would ensure that nobody has to navigate that painful experience alone, and I would love to work with the Government further on how we can develop it in an affordable and successful way to reach all communities, whether rural or inner-city.

Data collection is an important area that I feel has been left out of the conversation somewhat. It is vital that we understand the issue. There has been a push for the systematic recording of all miscarriages in order to understand their true scale. The numbers we quote today are unknowns, really, because we have not been recording them systematically.

I had an experience when being called for my flu jab. I was a bit bemused and asked why I had been called for one. They said, “Oh, it’s because you’re pregnant.” They looked down and saw that I was not pregnant and said, “Oh wait, you’re not.” That was a very difficult thing for me to go through. They did give me the flu jab, which is quite funny I suppose, but it was really hard for me to go to that appointment and hear that.

Many of my constituents have been asked whether it is their first child or how their other children are doing, because the notes are not there. The way that miscarriage and baby loss is flagged on medical records is not sufficient to stop those awkward and very upsetting experiences for women who have been through baby loss. We want to get national statistics because we want to understand the true picture. That will allow us to set targets and measure the impact of the interventions that we so desperately need to introduce.

Although the previous Government’s commitment to 20 short-term actions, including on some of the issues I have highlighted, is a positive step, it is deeply concerning that families are still having to face the trauma of multiple miscarriages before receiving investigative tests and mental health support, which is not fully understood either. People who have suffered loss are more likely to suffer from post-traumatic stress disorder, depression and suicide. These are very material issues for families who have experienced one miscarriage, never mind the trauma of three. I hope the Government can look into the issue in more detail.

We have heard about issues of inequality. Black babies are more than twice as likely to be stillborn, and black and Asian babies are more than 50% more likely to die shortly after birth than white babies. High rates of child fatality and miscarriage are also reported in the Gypsy, Roma and Traveller communities. This disparity is unacceptable. I urge the Government to renew and extend the national maternity safety ambitions and to set clear targets to reduce these inequalities. I welcomed the reviews of these two areas that were brought forward by the last Government, but I hope we can learn the lessons soon and get action for those mothers. Every baby deserves an equal chance of survival; their background should not matter.

We must also focus on improving prenatal care. This is an area that people are again not given enough information on. Early and regular antenatal care is critical, but if we can provide advice, guidance and support for women who have disabilities and illnesses, we can help them have safer pregnancies. As we have heard today, the basic care is still not there for many people, and it is essential for us to focus on that gap.

As I said, we need to ensure that every expectant mother has access to timely, high-quality care regardless of their background. Alongside that, addressing health inequalities is crucial; sadly, babies born into poverty are more likely to die by their first birthday than those born into wealthier families. That disparity is a stark reminder of the broader social determinants of health that contribute to infant mortality. We must tackle these inequalities head-on by improving access to healthcare, education and support for families—particularly those from disadvantaged communities.

Preventable baby deaths are a tragedy that we have the power to address and prevent. Although we have made important strides, more work is desperately needed. I urge the Government to commit wholeheartedly to giving every baby the chance to thrive and ensuring that every family receives the support they need throughout pregnancy and, unfortunately, throughout baby loss.

10:30

[Helen Morgan (North Shropshire) (LD)]

It is a pleasure to serve with you in the Chair, Mr Dowd. I start by thanking the hon. Member for Ashfield (Lee Anderson) for securing this important debate. Sadly, we have revisited this issue a number of times, even in the short period since I was elected in 2021.

Members’ speeches today have been excellent, and I will touch on them briefly. I thank the hon. Member for Ashfield for telling the stories of his constituents who have come along today, and I thank them for sharing their stories, which were very moving. It is tragic that they have been through such experiences.

The hon. Member for Clacton (Nigel Farage) addressed the fact that the subject is taboo and that we need to get over that if we are to support families properly. The hon. Member for Morecambe and Lunesdale (Lizzi Collinge), who I welcome to this place, stressed the importance of providing support for bereaved families and of the groups in her constituency that do that. The hon. Member for Strangford (Jim Shannon) told us the moving story of his constituent Agnes, who felt her loss for the rest of her life.

The hon. Member for Washington and Gateshead South (Mrs Hodgson) has been a pioneering campaigner on this issue. In particular, she has campaigned successfully on the issue of the birth and death certificate for a lost baby, and I am sure everybody is grateful to her for that. The importance of making memories for bereaved families is so important. The hon. Member for Rossendale and Darwen (Andy MacNae) pointed out the important statistics we need to consider and the importance of effective bereavement support. The hon. Member for Sheffield Hallam (Olivia Blake), who has also been an effective and tireless campaigner on the issue of miscarriage, made an excellent speech.

I became co-chair of the APPG on baby loss shortly after I was elected, because of the scandal at Shrewsbury and Telford hospital NHS trust and the Ockenden report, which was issued shortly afterwards. There have been similar incidents at Morecambe Bay and East Kent, and we suspect there is a similar issue emerging at Nottingham, with the review by Donna Ockenden currently under way. The fact that scandals have emerged across the country means that there are endemic failings that we need to address, rather than blaming individual trusts.

The reports on Morecambe Bay and East Kent were by Dr Bill Kirkup, while the Ockenden report was for Shrewsbury and Telford. They raised very similar issues, albeit in quite a different style. The first issue was the importance of safe staffing in ensuring that babies do not die unnecessarily on maternity wards. Sands and Tommy’s have also led a campaign on that, which the APPG supported. The former Government responded quite well in trying to improve midwife numbers and ensure that maternity units are safe places to be. Shrewsbury and Telford hospital NHS trust has achieved its targets on safe staffing. We need to keep the focus on that area, because safe staffing obviously needs to be maintained; it is not a one-off thing that we can do and then hope for the best for the future.

Other issues that came up include learning from mistakes, listening to mothers and their families, and doing a proper review when something goes wrong, as it inevitably occasionally will, to make sure that lessons are learned. It feels like that has not happened across the NHS as a whole. In every review, we have heard about a lack of openness and transparency with the families and about blame being passed on to mothers who have lost their babies. We have heard about a toxic environment in some hospital trusts and about a willingness to cover up what has gone wrong rather than be candid and learn from mistakes. Those issues have been highlighted time and again, and it is important that the three reports—we are expecting a fourth—do not just gather dust on a shelf somewhere. Action must be taken to ensure that those mistakes do not keep happening.

The hon. Member for Morecambe and Lunesdale raised the fact that there is an obsession with natural birth, and I feel that very strongly. After having an emergency C-section, I was asked by a midwife whether I felt like a failure for having been through that emergency medical procedure. The answer was, “No, not until you suggested that maybe I ought to,” but hon. Members can probably imagine the shame, guilt and depression that followed. We must get away from this obsession with natural childbirth. It is the best option for mothers with low-risk pregnancies, but it is not great for anybody who has a medical issue. We must not let ideology lead the evidence and science.

I am conscious of time, so I will not take too long. Shrewsbury and Telford hospital NHS trust has made great inroads in implementing the immediate and central actions that Donna Ockenden recommended, but I would welcome an update from the Minister on progress on the national actions. If the disparity for ethnic minority women—whether they are black, Asian or from another ethnic minority—was happening in an individual trust, we would be up in arms and would get in a professional to investigate what was going wrong. We must not lose sight of that disparity and inequality. We must deal with the terrible outcomes for some of these women, as well as with the wider situation in the NHS.

Independent whistleblowing is particularly important. In Shrewsbury and Telford hospital NHS trust, the freedom to speak up guardians report into hospital management, and people frequently report that they do not feel safe whistleblowing. I urge the Government to look at safe whistleblowing and to create an independent office of the whistleblower to ensure that when people raise medical concerns about safety, they are listened to, are not closed down and do not fear losing their jobs.

These scandals do not apply to a single hospital trust; there is huge variety in the quality of care across the country. I urge the Government to look at maternity care across the country and to ensure that getting safe care is not a postcode lottery but is consistent and fair for all women.

10:37

[Dr Caroline Johnson (Sleaford and North Hykeham) (Con)]

It is a pleasure to serve under your chairmanship, Mr Dowd. I congratulate the hon. Member for Ashfield (Lee Anderson) on securing the debate; the stories he read were very emotive.

Many people witnessing birth for the first time describe the experience as the miracle of birth. It is indeed the most wonderous occasion. I have been honoured to be present at the birth of many hundreds of babies in my work as an NHS doctor. Unfortunately, birth is an unpredictable process, and the hon. Member for North Shropshire (Helen Morgan) is right that we should focus not on natural birth but on the outcome of a healthy mother and child.

Birth does not always go smoothly. Generally, and increasingly as I became a more senior doctor, I attended only the very high-risk deliveries—those when things go wrong. In a job focused on saving lives, the opportunity to do so at birth is perhaps the most rewarding, but sadly, despite the best efforts of the whole team—midwives, obstetricians, paediatricians and allied professionals—some babies die, and that leaves a hole in the families that, as others have said, does not go away.

I spoke in the baby loss debate in 2022 as the responsible Minister, and I am reminded today of the words of Hayley Storrs, which were read by the hon. Member for Leeds East (Richard Burgon):

“What people fail to understand when someone loses a child, it is that you have lost a lifetime. First days at school, first steps, graduations, what their favourite story would have been, birthdays, Christmases.”—[Official Report, 25 October 2022; Vol. 721, c. 65WH.]

That very moving account has stuck with me. It reminds us that this pain endures, so we must do all we can to prevent it.

I pay tribute to my NHS colleagues who strive every single day to ensure that pregnancy and birth lead to the happy, healthy outcome that we all want. Politicians and the Government must do all we can to support that. We must hold the NHS to account when it fails to uphold the very highest standards.

I also pay tribute to the many great charities, such as Sands, Tommy’s and Bliss, which have been mentioned by others, that do such great work in this area. I was proud to run the London marathon with a constituent earlier this year to raise money for Bliss, and I am grateful for the support it provided to him.

We must focus relentlessly and systematically—starting at pre-conception, as the hon. Member for Sheffield Hallam (Olivia Blake) said—on every single factor that can cause or increase the risk of baby death. That includes reducing teenage pregnancy, smoking and obesity; ensuring that there is chronic illness optimisation, so that if someone has diabetes, it is optimally managed before they conceive; making medication changes if needed, so that someone is not taking teratogenic drugs at the onset of pregnancy; and ensuring that women are aware that folic acid should be taken before and during the early parts of pregnancy. Before the general election, the Government consulted on the fortification of flour with folic acid to reduce the number of babies who suffer from a shortage of folic acid during pregnancy. Can the Minister confirm whether this Government will go ahead with the proposed legislation to fortify bread products?

Additionally, the Chancellor has said that she will stop all non-essential communications. Many of the messages we are talking about are public health messages that need public communication strategies. Can the Minister confirm that this essential form of communication is not affected by the Chancellor’s restrictions on communication costs?

NHS England introduced the saving babies’ lives care bundle, which currently focuses on six areas: smoking; the assessment of foetal growth during pregnancy; awareness among parents and families that a reduction in foetal movements can be a significant warning sign; expertise training for cardiotocography monitoring during labour and pregnancy; the reduction of premature birth; and the management of diabetes to ensure that people have optimal control. The NHS had a plan to update the bundle to introduce maternal early-warning schools and tracking tools. Can the Minister confirm whether it is on track to deliver that? Can she also confirm that the saving babies’ lives care bundle will be updated this year and at regular intervals, as evidence improves on how we can best reduce the number of baby deaths?

Two years ago, as Minister, I delivered a statement to the House on behalf of the Government regarding the outcome of Bill Kirkup’s independent review of maternity services in East Kent. His report was very sobering. Those tragic events revealed failings—failings seen previously elsewhere, which should and must not be repeated. In response to the review, the Government set up a group chaired by Maria Caulfield, then the Minister for Women’s Health, to oversee the work being done to improve maternity services nationwide, including by implementing the recommendations in Dr Kirkup’s report. Can the Minister confirm that the group’s work will continue under the new Government? If so, can she confirm who will lead it?

Can the Minister confirm that she will support the work of the healthcare safety investigations branch, which investigates all cases of stillbirth and life-changing injury, to see what lessons can be learned and how care can be improved?

Other have talked about the Sands and Tommy’s “Saving Babies’ Lives” report, and particularly about workforce issues. The previous Government invested heavily in increasing workforce numbers, building five new medical schools. That takes time, but it will ultimately increase the number of obstetricians and paediatricians. The number of midwives also increased. There were 23,361 full-time equivalent midwives in NHS trusts and other core organisations in 2023, which is an increase of 19% since 2010. Births fell in England and Wales during a similar period. In the spring Budget, the Government committed £35 million to improving babies’ care, £9 million of which was related to preventing brain injury. The remainder related mostly to funding 160 additional posts in midwifery and neonatal care. Can the Minister confirm that that investment will proceed in order to support the care of pregnant women and babies?

In summary, it is almost 10 years since the Government launched the maternity safety ambition. While that goal has not yet been achieved, from 2010 to 2022, the stillbirth rate fell by a fifth, the rate of maternal mortality fell by a fifth, and the rates of neonatal mortality for those babies born after 24 weeks fell by 36%. Those statistics are a good achievement, representing many hundreds of families who will now enjoy watching with love as their children grow, thrive and develop. We must build on that now to ensure that many more families—all families—have the same opportunity.

10:44

[The Minister for Secondary Care (Karin Smyth)]

It is a pleasure to serve under your chairmanship, Mr Dowd, and to speak for the Government in this important and moving debate. I am grateful to the hon. Member for Ashfield (Lee Anderson) for raising this important issue. As my hon. Friend the Member for Washington and Gateshead South (Mrs Hodgson) said, it is the last taboo, and the hon. Member for Clacton (Nigel Farage) articulated well the difficulties that many people have in knowing what to say.

The debate gives me the opportunity to put on the record my deepest sympathies to the bereaved families: thank you for making the decision to come here today. Others might be listening in on the Parliament channel. The decision to attend is brave, and I commend the hon. Member for Ashfield for giving voice to the moving and harrowing stories of Emma and Rob, Bianca Chapman, Amelia Bradley and Hayley Moore, about their babies, Olivia, Imiza and Theo.

We know that preventable baby loss remains a serious issue every time such debates come before the House. Today, we have heard how many people have taken part in previous debates; I have listened in before. What little consolation they must be for parents and wider families who have lost a loved one, but I am always inspired. I hope that the families present today recognise that every Member of Parliament is also a human being, with their own experience and that of their families. The issue touches every family; as the hon. Member for Strangford (Jim Shannon) said, it stays with families for decades. Sharing such experiences is brave of hon. Members, but they have given voice to how important the issue is.

Every baby’s death is tragic, but all the more devastating when parents are told that it could have been prevented. As we have heard, report after report has told us that this remains a serious issue in our health service, and that is backed up by the data. Two years ago, the Office for National Statistics found that almost 2,300 stillbirths were recorded in England and almost 1,700 neonatal deaths, a rate of 2.9 per 1,000 live births.

In 2022, I welcomed the Ockenden review, as many did, but it made for harrowing reading. The Government’s position is that any preventable death is unacceptable. We are committed to ensuring that all baby deaths that can be prevented will be prevented. Donna Ockenden’s review shone a light on maternity staff too exhausted to do their jobs. It showed patterns of poor care, a lack of adequate training for staff, and failure in governance and leadership that led to widespread avoidable harm and death, and to shocking inequalities in maternity provision. Dr Bill Kirkup’s review of East Kent identified similar themes, but also showed that leadership and culture changes were needed. That is why this Government stood on a manifesto commitment to train thousands more midwives and to set an explicit target to close the black and Asian maternal mortality gap.

There are a number of initiatives, some of which we have heard about today, and I will run through some of them. If I do not address some concerns expressed by hon. Members in my update, we will get be in touch with people, including the official Opposition—I commend the hon. Member for Sleaford and North Hykeham (Dr Johnson) on her experience in this area as a clinician as well as a spokesperson.

The NHS put in place a three-year plan to deliver the reviews’ recommendations to make maternity and neonatal care safer, more tailored to every new mother’s needs, and more equitable. That includes the Saving Babies Lives care bundle, which is being rolled out to every trust. That provides maternity units with guidance and interventions to reduce stillbirths, neonatal brain injury, neonatal death and pre-term birth. That will need to be updated regularly, but I will confirm the details to the hon. Lady.

The plan also includes initiatives to reduce inequalities. As we have heard, a serious cause for concern is the higher rate of stillbirths, neonatal deaths and pre-term births among babies from the black and Asian ethnic groups. Babies of black ethnicity are about twice as likely to be stillborn as babies of white ethnicity. That is unacceptable in modern Britain. We will not rest until outcomes are equally good for everyone in this country.

We also know that women living in deprived areas, not least my own constituency, are more likely to suffer adverse outcomes. In 2022, the stillbirth rate per 1,000 births in the 10% most deprived areas in England was 5.0, or 389; in the 10% least deprived areas in England, the stillbirth rate was 3.7 or 155. All local maternity and neonatal systems have equity and equality action plans in place to tackle such inequalities. NHS England is investing £10 million every year to target the 10 most deprived areas of England.

Wider work is also important. NHS Resolution’s maternity incentive scheme is improving maternity safety by rewarding NHS trusts that demonstrate that they are taking concrete steps to improve the quality of care for women, families and newborns. The National Institute for Health and Care Research has commissioned studies into how we can prevent pre-term births and improve care for mothers and babies. This year it launched a £50 million funding call, challenging researchers and policymakers to come up with new ways of tackling maternity inequalities and poor pregnancy outcomes.

There are ongoing initiatives to ensure that lessons are learned from every individual tragic event and to prevent similar events from happening in the future. All hospitals already carry out internal perinatal mortality reviews, which create reports that aim to provide answers for bereaved parents about why their baby died. They also help hospitals to improve care and ensure they try to learn something from every tragedy, wherever it happens.

The maternity and newborn safety investigations programme conducts independent investigations of early neonatal deaths, intrapartum stillbirths and severe brain injury in babies following labour. All trusts are required to tell the programme about these incidents. It will then carry out an independent investigation and make safety recommendations to improve maternity services. Coroners are also required to investigate deaths that are violent, unnatural or of unknown cause, although their remit excludes stillbirths; but that should leave no stone unturned when it comes to uncovering the cause of death, including an inquest where appropriate. Additionally, as of June 2024, I am assured that all NHS trusts have signed up to the national bereavement care pathway, which many hon. Members have raised today.

The existing measures, taken together, are helping to achieve improvements; we have already heard about some of the positives. Since 2010, the neonatal mortality rate has decreased by 25% for babies with at least 24 weeks’ completed gestation, the stillbirth rate in England has decreased by 23%, and the overall rate of brain injuries occurring during or soon after birth fell by 2%. But we know, and have heard so movingly today, that more must be done.

People rightly expect assurances that lessons will be learned and that things that went wrong are not repeated. As hon. Members have pointed out, the sad truth is that we are likely to be debating these issues in the future, when the CQC releases its next report on maternity inspections and when Donna Ockenden completes her investigation into Nottingham. I expect to be speaking with hon. Members again about this issue, and my noble Friend Baroness Merron, Minister for Patient Safety, Women’s Health and Mental Health, will be following that very closely.

Many of the issues identified locally are being repeated across the country, so I am clear that national leadership is needed. The Government will be honest about the challenges facing the health service and are serious about tackling them. I will listen to women and their families and do everything I can as a Minister to help deliver safer and fairer maternity and neonatal services for women and their babies. I really commend hon. Members who have shared their experiences today— particularly new Members; I do not think I would have been able to do that as a new Member of Parliament. My hon. Friend the Member for Washington and Gateshead South spoke very honestly about how long it took for her to do that. That was valuable.

It may not be for me to say as Government Minister, but I commend the work that my hon. Friend the Member for Washington and Gateshead South and other colleagues across parties have done in the APPG on baby loss. They have raised these issues and worked with Government Ministers, which is really important as parliamentarians. I hope that is reassuring to families here today. That work will hopefully be continued by parliamentarians across the House. Perhaps that will be an outcome of the issue being raised today, so early in this Parliament.

We need to listen to these women and their babies. We need to make sure that we have the midwives and other staff necessary to keep women and their babies safe. Before I finish, I should say that if I have missed anything, hon. Members should please get in touch. I say to my hon. Friend the Member for Sheffield Hallam (Olivia Blake) that we welcome the Tommy’s miscarriage pilot, and my ministerial colleague will be looking closely at those recommendations.

As a new Government, we want to end sticking-plaster politics; that means real and lasting change in the health service. That will take time, but we will build a better future for women in this country. That includes by making sure that all baby deaths that can be prevented will be prevented.

10:54

[Lee Anderson]

First, I want to thank everybody for coming to this debate. It has certainly been an education for me—the number of Members who have all been touched by baby loss and turned up for this Westminster Hall debate is incredible.

During this debate, I have been educated about C-sections. When I went to my local hospital to talk about births and the number of C-sections as opposed to natural births, I asked the question: why are people having all these C-sections and why not just—and I apologise for this—make them have a natural birth? But actually, during this debate, I have come to understand why there are different outcomes for different people, and that sometimes a C-section is more appropriate for the woman. I know that it creates problems as well with the scarring and wounds and that sort of stuff, but I thank Members for educating me on that.

One of the most moving stories came from my good friend, the hon. Member for Strangford (Jim Shannon). As he said, this never leaves a family, no matter if it is 50 years on. These parents and family members will probably celebrate birthdays—first birthdays, second birthdays, the child’s fifth, their 10th, when they would have started school, their 18th and their 21st. They will go through all that because they will be around other children and young people who were born around the same time, and they will be thinking, “That could be my child in that class”, “That could be my child in that football team”, “That could be my child playing in that netball team”, and, “That could be my child going to prom in a Cadillac.” I thank the hon. Member for Strangford for that. He always speaks with great passion.

I thank all Members for all speaking with great passion and great dignity. It has been a wonderful debate—very sad, but a wonderful debate nevertheless. I thank the ministerial team and the shadow Minister, but most of all I want to thank those in the Public Gallery. They have been extremely brave. The families from Ashfield, the councillor and the lady from Sands have been incredible.

Question put and agreed to.

Resolved,

That this House has considered preventable baby deaths.