National Maternity and Neonatal Investigation
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The Secretary of State for Health and Social Care (James Murray)
With permission, Madam Deputy Speaker, I shall make a statement on the national maternity and neonatal investigation.
Less than a week ago, I stood at this Dispatch Box to respond to the report by Donna Ockenden that exposed devastating failings over more than a decade in Nottingham. As many right hon. and hon. Members rightly made clear following my statement, the shocking report into what had happened was far from the first: in 2015 we learnt of the failures at Morecambe Bay; in 2022 we were appalled to hear about what had happened at Shrewsbury and Telford; and that same year the Kirkup inquiry exposed failings in East Kent. There were also other reviews and reports over the years on specific issues related to maternity care, and it is deeply upsetting to recognise that Donna Ockenden is preparing to undertake further reviews into failings in Leeds and Sussex. Despite all the warnings, the NHS is still failing women, babies and their families on a scale that shames our society.
Bereaved and harmed families are hearing once again the unbearably painful and distressing consequences of the opportunities that have been missed to put things right. As I stand here, I think of how they must be feeling. I know from meeting some of the Nottingham families that their unwavering determination is accompanied by a sense of exhaustion—a sense that however many times they have told their stories, however hard they have campaigned for justice and accountability, and however strongly they have fought to stop what happened to them from happening to others, hardly anything has changed. That feeling will be shared by mothers and their families up and down the country who have suffered so appallingly too, and there will be deep sadness and distress as they are forced to relive their trauma. The burden they bear must sit with us all.
That is why my right hon. Friend the Member for Ilford North (Wes Streeting) decided last year to announce a national investigation into maternity and neonatal services. That investigation has been carried out by Baroness Amos, whose report is published today. I put on record my thanks to her and her team for the comprehensive and compassionate way they have carried out their work.
The Amos investigation gathered evidence from more than 10,500 people, with Baroness Amos and her team personally meeting more than 450 affected families. They visited 12 NHS trusts and heard from over 9,000 staff through surveys, site visits and one-to-one discussions. Although they found that many women experience good and safe care, the report paints a bleak picture of failings at every stage for too many: from pregnancy, labour and delivery to the first hours, days and weeks after birth. When I read about those systemic failures, I found them not only shocking and upsetting but devastatingly familiar, because they are explicitly repeated in review after review. Baroness Amos found a system that is fragmented, overly complex and far too slow to learn. It needs to be radically overhauled.
Last week I spoke about the need to avoid having review recommendations accepted but then sitting on a shelf gathering dust. Other hon. Members agreed with the need to break that cycle, so that is what we will do. As I told the House last week, the national maternity and neonatal taskforce, which I chair, will create a comprehensive action plan by the end of this year.
Today’s recommendations from Baroness Amos include a proposal for a modern service framework in line with the 10-year health plan to support system change and drive consistent, quality care. Those recommendations, along with the national-level recommendations from Donna Ockenden, will feed into our plan, which will make sure that women and babies receive safe, compassionate care no matter where they live. But I do not want people to have to wait for the plan to be completed for us to start making progress, so I am also taking immediate measures in response to Baroness Amos’s investigation, which I shall now set out for the House.
In considering Baroness Amos’s recommendations, the words of a Nottingham mother I met ring loudly in my ears. She said that “accountability drives action”, so today I can confirm that, in response to these recommendations, the Government will appoint the first ever maternity and neonatal commissioner. The holder of this new statutory role will have responsibility for driving change across all parts of the NHS, including those who provide, regulate and investigate care. They will co-chair the national taskforce, along with me. They will hold the system to account, and their role will be to champion the voices of women, babies and families; to ensure that those voices are heard within Government when decisions are made and implemented.
Last week I announced that the Government would roll out Martha’s rule, so that women and their families can demand a second opinion if they feel their concerns are being ignored. That meets a key and familiar concern that the Amos investigation pointed to: women not being listened to as a common factor in maternity failings. Because those concerns are too often batted away before women even arrive at hospital, I can today confirm that we will this week publish new national standards for maternity triage, so that care is consistent across the NHS and women’s concerns are recognised, valued and acted upon at every turn. I expect every trust to prioritise the implementation of these standards and I have asked NHS England to make sure that this is the case and to report progress directly to me.
Some of the starkest examples of racism, discrimination and inequality happen in maternity and neonatal settings, as the Amos report laid bare. The result is that the risks are notably higher for some women and babies and, as Baroness Amos points out, this is a critical safety issue. Black babies are still more than twice as likely to be stillborn as white babies, and black women are almost three times more likely to die during pregnancy or shortly after birth than white women. While tackling inequalities will be a core component of the national action plan, we will make a start straightaway by rapidly expanding the roll-out of the perinatal equity and antidiscrimination programme to every trust. All teams will be mandated to receive hands-on support, to hear first-hand experience, and to undertake face-to-face learning and development programmes. Every trust will have completed the programme by the end of next year.
Births that are safe for mothers and babies depend on health services having skilled, trained midwives. As Baroness Amos rightly identified, staff shortages can have a dangerous impact, with examples of some services being forced to delay admissions when they get too busy. Since coming to office, we have recruited 2,000 more midwives, and last year our graduate guarantee gave 850 more newly qualified midwives an immediate route into the profession. I can tell the House today that we have now created a further 1,000 temporary roles to help newly qualified midwives join the NHS. These new posts will be accompanied by investment, too, and I can confirm that we are investing an extra £41 million, on top of the £145 million already invested, to upgrade outdated and rundown maternity and neonatal facilities.
Alongside these practical measures comes a far more profound challenge that we must face. It is clear from my conversations with affected families, with Donna Ockenden and with Baroness Amos, and from the findings of all the reports, that culture is where so much of the responsibility lies. That culture is the most deep-rooted cause of the failures we have seen, and the most fundamental thing we must change. We know that when families have been in distress and looking for answers, they were too often ignored, sneered at, disbelieved, blamed and lied to. We know from review after review that wrongdoing is covered up and that bullying towards staff who try to sound the alarm is rife, so we will dismantle toxic dynamics, boost staff morale and support better teamwork between midwives, doctors and other clinicians.
We need not only the right policies, procedures and processes to be in place, but a fundamental reset in the culture of a service that too often puts the desire to protect itself above its duty to protect women and babies. That culture change must come from the top. It is time for trust leaders, executives and senior clinicians to pay attention to what is happening on their watch, to put professional tribalism aside, to lose the bunker mentality when things go wrong and to ensure that the safety of women and babies always comes first.
This has to be a watershed moment. We must break the cycle of recommendations sitting on a shelf gathering dust. We cannot go on having review after review while women and babies, as well as their fathers and other family members, continue needlessly to suffer injury, death and lasting trauma. We should all feel a responsibility to ensure that this opportunity is not squandered. We owe nothing less to every family the NHS has failed in the past, and to every family who will rely on it in the future. I commend this statement to the House.
Madam Deputy Speaker (Caroline Nokes)
I call the shadow Secretary of State.
Stuart Andrew (Daventry) (Con)
I thank the Secretary of State for advance sight of his statement, and I thank Baroness Amos and her team for their compassionate work. As I said last week, I pay tribute to the women and families who gave evidence and to the babies at the heart of the inquiry. Many revisited the most painful moments of their lives after years of fighting to be heard. Their courage places a responsibility on us all.
Last week, the House confronted Donna Ockenden’s devastating findings in Nottingham. Today we face the wider national picture. Successive investigations expose the same failures: women dismissed, deterioration missed, staff silenced, inequalities unchallenged and leaders failing to learn. The problem is no longer a lack of evidence; it is a failure to act. Donna Ockenden said this morning that, sadly, so much in this report is stuff that we already knew. She also raised concerns about waiting until December, and I welcome the fact that the Secretary of State has just announced some of the work. She also said that no commissioner alone can fix a system needing action from every level from the Secretary of State right down to every ward. Donna Ockenden commands enormous respect and we should all listen to her, because she is right.
When will the Leeds and Sussex reviews produce their reports, and how will Ministers act on concerns before they conclude, so that families in those areas can see the change that they need as soon as possible? Families should not have to keep proving the scale of harm. Their testimony must now lead to action. The Birth Trauma Association says that the report has overlooked serious injury to women and brain injury to babies, so will the action plan address those harms, and how will families shape and scrutinise it?
We welcome the work beginning immediately on triage, discrimination, staffing and urgent estate risks. This is so important, and we must get on with that work, but families cannot wait until the end of the year for the wider plan. Those expecting babies now need reassurance about what will change and when. So many must be anxious, and we need to do all that we can to reassure them. The new triage standards will be published this week. By when must every trust meet them? Will the Secretary of State commit to update the House, by oral or written statement, on trust-by-trust progress? Will the estates funding include accommodation for parents close to neonatal units so that families are not separated from their critically ill babies?
We do not oppose a statutory maternity and neonatal commissioner, but Ministers must be clear about the role’s purpose, powers and accountability, because just one person cannot bring the change that is needed; local leaders have a responsibility too. When will the commissioner be appointed, and what will they be able to compel trusts, regulators and national bodies to do? How will local leaders be held accountable when care remains unsafe?
The additional midwifery posts are welcome, but temporary roles are not a sustainable workforce plan. Donna Ockenden has warned of rota gaps and of staff leaving obstetrics and midwifery. The 10-year workforce plan has been promised, delayed and pushed back repeatedly. When will it finally be published, and will it provide the permanent workforce that these recommendations require? With women having babies later and pregnancies becoming more complex, how will those at higher risk receive early specialist care?
I agree with the Secretary of State that the culture has to change. Listening to women is a clinical duty, not a courtesy; as I said last week, it is at the core of our safety issues. When concerns are dismissed, warning signs are missed, and mothers and babies are put at risk. That duty must apply equally in respect of every woman. A woman’s safety must not depend on her ethnicity, first language, disability, income or ability to fight through the system. As I said last week, both to the House and to the Secretary of State privately, I want us to work together constructively. Where the Government act with the urgency that the report demands, they will have our full support. We all have a duty, and ours is to support these changes.
Women and families will not judge today by new structures, promises or another report. They will judge it by what happens when a woman says that something is wrong. Is she heard? Are warning signs acted on? Is senior help available when needed? Are maternity units safely staffed? Can staff speak without fear? Do families receive honesty and compassion when harm occurs? Are fewer mothers and babies coming to harm? When decisions are taken, will they be fully explained?
The evidence has been gathered. Families have told their stories. The system has been warned. Now it must change.
James Murray
I thank the shadow Secretary of State not only for his questions, but for his tone and approach. When I gave the statement about Donna Ockenden’s report last week, we all agreed that the responsibility to deliver real change is shared by everyone in this House, so I appreciate his approach.
The right hon. Gentleman asked about the investigations in Leeds and Sussex, to which Donna Ockenden will be turning her attention over the rest of this year. It might be helpful for the House to understand that in developing a comprehensive action plan through the national taskforce, a framework will be devised so that any recommendations from future reviews can be incorporated into that plan and its implementation. That will ensure that we do not have a situation in which the plan is developed and future reviews come to conclusions or recommendations without a clear way for those to be integrated into the action plan. I hope that that gives him some reassurance over the process.
The right hon. Gentleman spoke about recognising families who have been harmed, as well as babies who survived and have grown up into children and adults while living with the harm of failings in maternity care. I am very conscious of them, not least because of the people I have met who sometimes feel forgotten or feel that their children are forgotten when we have these conversations. They live with the impact of brain injuries or other issues that arise during birth. They must not be forgotten, and I will ensure that they are included in the process.
The right hon. Gentleman asked about the roll-out of the new national triage standards, which will be published this week. The NHS England chief executive is meeting with NHS system leaders today to begin the process of ensuring that the triage standards, along with some of the other urgent measures that I have spoken about today, are rolled out. Although it is right to take time to get the comprehensive action plan in place by the end of the year, we do not want to waste time before we get on with the measures that we have decided should progress more quickly. NHS England leadership is progressing with those today.
The right hon. Gentleman asked about the funding for critical safety works in the maternity estate. Those critical safety measures are important, but the action plan will set out a more comprehensive approach not just for the physical infrastructure, but for the culture, which we have spoken about many times. We cannot invest money in culture in the same way as we can do so in physical infrastructure, but it is something that we need to address. We all agree on that. I sense that I had agreement from the House when I raised the importance of addressing cultural problems in maternity services.
The right hon. Gentleman asked about the responsibility being placed on the commissioner as just one person. I reassure him that my vision is for the commissioner to play a crucial role, but not on their own: they will co-chair the national taskforce with me, help to ensure that the national action plan is implemented, hold the system to account and, crucially, be a voice for women in the system. One way of the Government starting to address the issue of women being ignored in maternity services—an issue I have heard about so many times—is by ensuring that the commissioner is a voice for them when decisions are taken.
The temporary roles are an immediate step this year to ensure that newly qualified midwives have a way into making a contribution to NHS maternity services. Funding for those will be baselined in future years, and trusts will decide, trust by trust, how the funding is distributed among different roles. That will vary depending on needs in local areas.
The right hon. Gentleman also spoke about the importance of identifying women who are at higher risk because of different circumstances or problems they may face in giving birth. That is exactly what I hope the new triage standards will begin to address. If the triage standards can identify issues before they escalate and ensure that women get the right support more quickly, we will have an opportunity to avoid the extra, avoidable harm caused to women by delays in getting the right support.
The shadow Secretary of State closed his remarks by talking again about the need for a change in culture. He talked about the support from the Opposition, who will of course robustly challenge us where appropriate but support the aims that we are seeking to achieve. I thank him for that.
Several hon. Members rose—
Wes Streeting (Ilford North) (Lab)
May I add my thanks to Baroness Amos? I join the Secretary of State in emphasising the importance of culture change, but culture change will not happen without accountability. In all the conversations I had with families who were suffering bereavement, harm to themselves or harm to their children, what shocked me most was the cover-up culture in the NHS, which persists to this day, and was exposed once again by Donna Ockenden in her report last week.
There is a legitimate debate to be had about whether we continue with place-based inquiries or have a national statutory public inquiry, and we must have that debate. But whatever the answer to that question, any report will be worth the paper it is written on only if all those involved in decision making and care are held to account through a duty of candour. Given that, where is the Hillsborough law? The law is important not just for justice for the 97, but for justice for these families and in preventing future harms. Will it at least go through this House before the summer recess? Until it is on the books, people will continue to duck the real questions.
James Murray
I thank my right hon. Friend for his comments, and again put on record my thanks and tribute to him for having initiated the investigation that Baroness Amos published today. He has been a committed champion of change in maternity services in this country.
I could not agree with my right hon. Friend more about the importance of accountability in culture change. Without accountability, we will not have culture change across maternity services, and the culture of cover-ups will continue. Senior clinicians will feel that they can continue to get away with any mistakes. They will feel that they can avoid scrutiny when investigations take place, and will continue, in too many cases, to be more concerned with protecting themselves than with protecting women and babies.
On what we can do to change that culture, culture is deep-rooted and requires us to take a number of different actions, but the duty of candour is the single most powerful change we can make clearly, loudly and publicly, because the message it will send to senior clinicians thinking about what to do in the future if they make a mistake, or if they are tempted to cover up things that go wrong, is that one day they will be held to account, and there is no avoiding that. With a duty of candour in place, there will no longer be an opportunity for clinicians, in particular senior clinicians, to refuse to engage in that process, to refuse to be held to account and be part of the justice process. People will face up to two years in prison if they refuse to co-operate, so it is a serious measure. I very much agree with him on the importance of ensuring that the Hillsborough law gets on the statute book so that this duty of candour can apply to future maternity investigations.
Helen Morgan (North Shropshire) (LD)
May I also add my thanks to the Secretary of State, to Baroness Amos and her team, and to the families that have relived the pain of their experiences to bring about this report? But the Amos report tells us little that we did not already know—indeed, it confirms our worst fears. Maternity services in England are fundamentally broken with the cost of political neglect being paid in trauma, injury and lost lives. Figures revealed by the Liberal Democrats in the last week show that the first quarter of 2026 saw the worst rate ever recorded for maternity injuries. In fact, while the number of reviews into NHS maternity services has steadily ticked up, we have also seen rising maternal mortality rates.
Four years ago, I spoke in this Chamber in response to the findings of the Shrewsbury and Telford review, which were devastating for my community. Last week, I stood here really distressed, actually, as we heard further traumatic reports from the Nottingham review. But anger is not enough. The Government must meet this moment now and implement Baroness Amos’s recommendations in full and without delay, or the families simply will not forgive them. To do this, we need genuine accountability through the NHS and the Department of Health and Social Care, accompanied with the investment needed to make Britain the safest country in the world to have a baby.
I welcome the Government’s commitment to a national maternity commissioner—a long-standing Liberal Democrat campaign—and the other urgent and immediate actions that the Secretary of State has outlined in the last week. They are all urgent and are signs that this is being taken seriously. But we need to recognise that a commissioner alone cannot fix the broken system. I urge the Secretary of State to work with us and look at our maternity rescue package for inspiration for his action plan—it has a great degree of overlap with Baroness Amos’s recommendations. Our package would ensure one-to-one midwifery care for every woman in labour, additional senior midwives, an obstetrician on every ward, and mandatory updated annual training. Will the Government commit here and now to implementing all those recommendations and working with us to deliver the change we need?
James Murray
I thank the hon. Lady for her comments, and she puts it well when she talks about Baroness Amos’s investigation confirming our worst fears. I was shocked but not surprised, sadly, to read the investigation report. It was devastatingly familiar to read what it set out as being the failings across the country. The report’s recommendations will now become part of the work of the taskforce, which I chair, to produce the comprehensive action plan by the end of this year. My intention is that the taskforce will take all the national recommendations from Baroness Amos’s report, as well as the national-level recommendations from Donna Ockenden’s report last week and recommendations from any other investigations and reports, and ensure that the action plan it produces comprehensively addresses all the issues raised. I think that we would all agree that there is not—one, two, three—a small number of actions that we need to take; this has to be a comprehensive plan to truly transform the service.
Ms Diane Abbott (Hackney North and Stoke Newington) (Ind)
The Secretary of State will know that many women are never more vulnerable than in childbirth. It is about not just the vulnerability, but the horror of what women and their babies are exposed to in childbirth. We see inquiry after inquiry, and nothing seems to improve. Very many of those who suffer during childbirth are black women and their babies. The Secretary of State said himself that
“Black babies are still more than twice as likely to be stillborn than white babies, and black women are almost three times more likely to die during pregnancy or shortly after birth than white women.”
The whole House wants to see progress, but it is not enough to have another inquiry or another report; what black women want is equity of treatment and fewer black women and their babies dying.
James Murray
I thank my right hon. Friend for her comments and agree about how shocking the failures in maternity services are, particularly because these failings and the failure to listen to women happens at a point when they are at their most vulnerable. It is at that moment when they are let down. When they need the NHS the most is when the NHS fails them, and that is one aspect of this that makes it truly devastating.
My right hon. Friend also rightly highlights the impact on black women and their babies, who are at more risk than white women and their babies, and the inequalities that exposes. As I mentioned during my earlier statement, we will begin by ensuring that the perinatal equity and anti-discrimination programme is extended to all trusts by the end of next year, but that is an immediate measure we are taking rather than the sum of all measures that we will take on this front. Inequality, racism and discrimination will be a central part of the action plan that the taskforce develops.
Sir Jeremy Hunt (Godalming and Ash) (Con)
I strongly agree with the comments of the former Secretary of State, the right hon. Member for Ilford North (Wes Streeting), about the need for getting the culture right with accountability. When I was Secretary of State, we passed the duty of candour regulations. They were supposed to make it—well, they do make it—a criminal offence for trusts not to tell the truth to families when a tragedy has happened. Yet to this day, trust lawyers advise doctors, nurses and midwives not to be open about what has happened when there is the prospect of legal action further down the line. Does the Secretary of State—I know he is very committed to this—agree that we will clear up this anomaly in the Hillsborough law so that it is just not possible for trusts not to tell the truth and so that trust lawyers always advise their own doctors, nurses and midwives that they must tell families exactly what happened?
James Murray
I thank the right hon. Gentleman for his comments. Again, I agree with him and my right hon. Friend the Member for Ilford North (Wes Streeting) on the importance of accountability for changing culture. During the statement on Donna Ockenden’s report last week, he commented that this is about having accountability structures embedded throughout the system, because this is not something that the top of the NHS, the NHS chief executive, the Secretary of State or the ministerial team can control throughout the NHS. The structure has to be embedded to ensure that accountability happens at every level—something I very much took to heart and agree with when it comes to what we need to do next.
On the right hon. Gentleman’s specific point about the Hillsborough law and how that will address the issue that he refers to about legal departments effectively advising a cover-up, that sounds concerning, so I will look into that as part of our work to ensure that the system works properly. The expectation with the duty of candour, which will come in under the Hillsborough law, is to ensure that we never again have a situation as happened in Nottingham—I could not quite believe it, if I am honest—where many senior clinicians simply refused to take part. It is outrageous. It is unacceptable that so many senior clinicians were able to, and felt able to, just say no. That is not accountability if it is optional, and that is what we need to change.
Andy MacNae (Rossendale and Darwen) (Lab)
I hugely welcome the report and join in the thanks to all those who made it possible, but most fundamentally the families who shared their experiences and showed extraordinary courage through the whole process. Many of those stories were shared with us in the all-party parliamentary group on baby loss, and I assure those families that we will carry on listening to and being a voice for them through this process.
The reports makes many powerful recommendations—I welcome the action plan and the maternity commissioner—but the Government must retain responsibility for the ultimate outcomes. Following the expiration of the national maternity safety ambitions in 2025, will the Secretary of State recommit to meaningful targets to reduce stillbirths and neonatal deaths and introduce a target to finally fully eliminate inequalities in baby loss?
James Murray
My hon. Friend draws out an important point: a key part of developing the national action plan is to ensure we have the right metrics and mechanisms for monitoring its implementation and the right structures in place to make sure it is implemented across all trusts. In working with members of the taskforce, I will ensure that those accountability mechanisms for the delivery of the plan are in place, because I have spoken many times today about the importance of recommendations not sitting on shelves. We need to ensure we have the structures in place such that the actions in the national action plan are implemented, we can see they are being implemented, and we can give people confidence that that is the case.
Madam Deputy Speaker (Caroline Nokes)
I call the Chair of the Health and Social Care Committee.
Layla Moran (Oxford West and Abingdon) (LD)
I, too, thank Baroness Amos, her team and, most especially, the families who so bravely gave the evidence that has formed this report. Further to the conversation about accountability, the Secretary of State will have noticed that some families are concerned that the commissioner is just one person, and that there is too much for them to do. Can he make clear that the buck stops with him and, indeed, the PM, and that he will not let go of this? The commissioner will report every six months to the Health and Social Care Committee—we welcome that—and once a year to Parliament. Further to that, will he personally commit that the Secretary of State will seek permission from Mr Speaker to make a statement to the House once a year, so that they can be held personally accountable for the progress made too?
James Murray
In describing the role of the commissioner, the hon. Lady is right to emphasise that it cannot all be on one person. The commissioner is a vital role, and it being on a statutory basis will give the position real weight within the system to hold the system to account and help the Government to ensure the implementation of the comprehensive national action plan. But she is right to say that accountability has to include the Secretary of State and the Prime Minister, because it is a duty that we all hold as MPs, that the Government hold and that I hold as Secretary of State, and the Prime Minister ultimately holds that responsibility too.
It is not in any sense intended to be a passing of responsibility to a commissioner. The commissioner role is being established to support the effectiveness of the work we are seeking to do as a Government to implement the national action plan, but crucially, when accountable politicians are taking decisions, the commissioner will be a voice for women in the system. I have heard so many times that women’s voices are not being heard in the healthcare system, particularly when things go wrong and women have concerns in maternity services. This commissioner will be a way of making sure those voices are right at the heart of decision making.
Florence Eshalomi (Vauxhall and Camberwell Green) (Lab/Co-op)
I thank the Secretary of State for making this statement. I pay tribute to the noble Baroness Amos for her work and the care and dedication with which she has produced this report, and to the many women who came forward with their testimonies. I think back to the concerns that I raised just over nine years ago, when I was giving birth to my second son. Nine years on, women are still being dismissed, still not being listened to and still being silenced when they raise those valid concerns.
I pay tribute to the hard-working midwifery team at St Thomas’ hospital across the river, who continue to care for many women. I also want to highlight the Southwark Maternity Commission, led by Councillor Evelyn Akoto, and the work of organisations like Five X More, which continue to expose the issues faced by black and minority ethnic women. We also have to highlight the concerns of black and minority ethnic staff, who are told by some patients that they do not want to be served and helped by them. When will the real action plan be published? How will it create accountability to ensure that doctors and clinicians actually listen to these women?
James Murray
The action plan, which will be developed through the taskforce that I chair—the commissioner will co-chair it when that position is established—will publish its national action plan by the end of this year. That will consider all the recommendations from Baroness Amos’s report, as well as Donna Ockenden’s reports.
My hon. Friend makes a point that is worth drawing attention to, which is that many midwives and others working in maternity services do a really important job and work really hard to provide excellent care to women. That is not to diminish the scale of the failings, but it is to give the right perspective on all those midwives who do a really important job and work hard to care for women and their babies. That is evidenced by the fact that 9,000 members of staff came forward to give evidence in Baroness Amos’s investigation—they are concerned, and they want to see change as well. While this is, of course, primarily about women and their babies and families, staff also have a really important voice in this, and we need to improve the system so that they can make their contribution as well.
Alicia Kearns (Rutland and Stamford) (Con)
This week last year, I had multiple pulmonary emboli only a few weeks after giving birth. I am very grateful to Dr Laura Stephens, who saved my life and then was punished for ordering the test which found the emboli. Blood clots are the No. 1 cause of death in pregnant and post-partum women, and yet there is not a word about their risk in any pregnancy pack given out in this country. The national action plan will fail if it does not tackle blood clots as the No. 1 cause of maternal deaths. Will the Health Secretary kindly meet me and work with me, so that together we can save lives?
James Murray
I thank the hon. Lady for sharing her experience and raising the importance of this issue for the benefit of maternity services more widely. I am very happy for myself or one of the ministerial team to meet her to discuss this in detail, because it is very important that that is part of the national action plan and our wider response.
Jen Craft (Thurrock) (Lab)
I very much welcome the report and Baroness Amos’s work to highlight the failings across our maternity system. It is pure and utter medical misogyny that has led us here. The value that we place on the lives and experiences of women has been brought to the fore, and it is very, very low. The throughline of this report and the ones before it is that women’s voices were not heard, their pain was not believed, and their experiences were completely and utterly disregarded. That must change.
I would like to add my voice to the calls for measures to address the disparity in treatment for black and ethnic minority women. There must be proper training and continuing professional development to ensure that black women do not have the experiences that we have seen to date. I also plead with the Secretary of State to ensure that any proposals contain real accountability measures. I have a maternity unit in my constituency that is inadequate and has always been rated inadequate or “requires improvement”, but I have never seen a senior member of staff ever hauled over the coals. That cannot be right and it has to change.
James Murray
My hon. Friend is absolutely right to call this what it is in many cases, which is misogyny in maternity services, and to draw attention to the different impact on different mothers and the racial and ethnic inequality within the system. The anti-discrimination programme that I mentioned, which is being rolled out over the next year and a half, will be an important first step, but it cannot be the sum total of what we do to address discrimination and inequality. That will be a focus of the national taskforce, as will—to repeat a point many Members have rightly made—accountability, because it is only by embedding accountability throughout the system that we can be truly confident of change.
Andrew George (St Ives) (LD)
Like others, I welcome this report. The Secretary of State referred to Dr Bill Kirkup, who resigned from the Amos review as an adviser because he felt that it was skirting around certain birthing ideologies and caesarean targets. The Secretary of State said that “staff shortages can have a dangerous impact”, and indeed they can. Although he and Baroness Amos refer to culture, a lot of that culture is to do with budgetary and other pressures that result in members of staff on the frontline being belittled and discouraged from blowing the whistle about unsafe staffing levels. Will the Secretary of State look again at the report, and consider for the first time introducing mandatory safe frontline staffing levels for these services?
James Murray
The hon. Gentleman raises an important point about ensuring the right levels of staff and training, and about ensuring that the right structures are in place. I know from seeing Baroness Amos’s report, and from the recommendations in Donna Ockenden’s report last week, that those questions will be central to the work of the taskforce in developing the national action plan. As I have said a few times today, it is not the case that there are simply one or two levers that we need to pull, or actions that we need to take, to bring about change; however, the issues that the hon. Gentleman mentions are clearly central to what we need to do.
Josh Fenton-Glynn (Calder Valley) (Lab)
I echo what was said by my colleague from the Health and Social Care Committee, the hon. Member for Oxford West and Abingdon (Layla Moran). Baroness Amos pointed to workforce challenges and their impact on care and safety, and she noted that 67% of midwives reported burnout. Meanwhile, a General Medical Council survey found that 63% of obstetrics and gynaecology trainees had a high or very high workload. That is higher than the 42% average. The workforce plan has to address those problems—but will it?
James Murray
My hon. Friend asks a question about staffing, and ensuring not only that we have the right levels of staffing, but that people in the service have the right responsibilities, so that we do not have members of staff suffering from burnout or having a workload that they cannot cope with. Those are critical issues that the taskforce will consider in its development of the national action plan.
Sir Julian Lewis (New Forest East) (Con)
Last Wednesday, and again today, the Secretary of State expressed his shock at the number of senior clinicians who refused to take part in the Nottingham review. May I repeat a suggestion that I made last Wednesday? Those clinicians should be named publicly. That is a step that he could take straight away. If a parliamentary question for written answer is tabled, asking him to name those clinicians, will he answer it? I cannot think of a better or more justifiable use of parliamentary privilege.
James Murray
I will take away the right hon. Gentleman’s suggestion and think on it, because it is critical that we have accountability. As I said in response to earlier questions, I find the decision of senior clinicians not to take part in the Nottingham inquiry utterly unacceptable, and incomprehensible on a personal level. We must ensure that that never happens again.
Ben Coleman (Chelsea and Fulham) (Lab)
I am not a doctor, but thank you so much, Madam Deputy Speaker. Perhaps I am a doctor from the university of life—who knows?
I pay tribute to Baroness Amos for this excellent report, and to my right hon. Friend the Member for Ilford North (Wes Streeting) for commissioning it. It is a remarkable piece of work. It follows on from Ockenden, and the report on black maternal health done by my Health and Social Care Committee—its Chair, the hon. Member for Oxford West and Abingdon (Layla Moran), sits on the Opposition Benches. We see the same problems again and again: misogyny, racism and a lack of accountability. I am therefore delighted that this plan will be developed in six months, through the taskforce, and that we will have a maternity commissioner. I know that my constituent Louise Thompson, who has been campaigning hard for this position to be created, will be delighted. However, like me, I think she will have a question about timing. Will it be possible for the commissioner, who will be introduced on a statutory basis, to be brought in quickly enough for them to have a full role in shaping and creating the plan that will be before us in six months? If not, why not?
James Murray
My hon. Friend asks about the timing, and the process for establishing a commissioner. As a first step, in the next two weeks, I will meet members of the taskforce to agree the scope, and a detailed role for the commissioner, because I want that scope and role to be agreed with them, given that they will be developing the national action plan. We then need to get the commissioner on a statutory basis, and I want to do that as quickly as possible. I am keen to look for options to do that through the Health Bill, but that will obviously be subject to discussions with the usual channels. Once that is in place, we can appoint the commissioner as quickly as possible.
It is worth emphasising that the role of the commissioner will be to implement the national action plan, so work on developing the plan and on establishing the commissioner will begin immediately. When the commissioner is appointed, they will have a role in implementing the national action plan. The issue is not simply about developing a national plan; it is about ensuring that it gets implemented, and that we hold trusts and other organisations across the system to account.
Rosie Duffield (Canterbury) (Ind)
Our APPG on birth trauma report in 2024 was the first in Parliament on that subject. We heard from more than 1,300 women and families. The report was titled, “Listen to Mums”. I am glad that an independent maternity commissioner will finally be implemented, after our years of calls for one. Bill Kirkup’s headline finding in his 2023 review of east Kent was also that we should listen to women. The Health Secretary has repeated the importance of listening to women—the mothers, midwives, and experts, and even the MPs who have worked for years on this issue. Why does he think that we have not been listened to, and are often not even invited into the room? How will he work to demonstrably change that in his time in the Department?
James Murray
The hon. Lady is absolutely right to draw further attention to the issue of women being ignored in health services generally, but specifically when it comes to maternity services. That goes back to the culture in maternity services. It is a devastating conclusion to come to, but we see a culture there of misogyny, of women being ignored, and of their concerns not being listened to and acted on. We need to change that culture, and one of the first actions that we can take to do so is to have accountability. We must ensure accountability, through the duty of candour that we have discussed, and through other actions that we can take to enhance accountability throughout the system. That is a critical first step in ensuring that we change the culture.
Michelle Welsh (Sherwood Forest) (Lab)
I welcome Baroness Valerie Amos’s review, and I thank her and her team for their commitment to this vital work. Once again, this review confronts us with a very uncomfortable but real truth. The reality is that this inquiry and the Donna Ockenden inquiry did not come about because of a system, NHS England or a regulatory authority; it came about because families have to keep on speaking up, over and over again, about one of the most horrific and traumatic things ever to happen. All the while, there is a culture within of mutual protection, and a code of silence, which has enabled some staff to shield each other from consequences.
I welcome the recommendation on the national maternity and neonatal commissioner—a strong, independent voice with the power to challenge—but we know that one appointment alone will not solve the problems. We need fundamental reform of the wider system of oversight and accountability. Regulators, NHS bodies and inspection regimes must change. Reviews do not save lives, but action does. We need strong leadership; big, bold decision making; and a determination to implement change, rather than simply to recommend it.
James Murray
My hon. Friend is absolutely right. I again put on record my thanks to her for supporting families in their fight for justice and accountability. She is absolutely right to say that families have driven this work. It is families who have had the determination, persistence and stamina. It is quite hard to imagine people having those qualities when they are dealing with such unimaginable pain that lasts their whole life, but that is what families have done. That is why I feel that it is our responsibility to ensure that they do not have to drive these changes alone. We as MPs, Government Ministers and Secretaries of State support families in the drive for accountability, justice and change. My hon. Friend is absolutely right; this must be about fundamental reform to all parts of the system, including the regulators, which have let women down far too often.
Sir Bernard Jenkin (Harwich and North Essex) (Con)
Will the Secretary of State keep an open mind as to whether it is right to abolish the Health Services Safety Investigations Body, which was specifically designed to provide for a duty of candour? Clinicians would be obliged to give evidence to HSSIP; they could not refuse, and there would be criminal penalties if they did. As we have already established, the duty of candour, as conceived in the Hillsborough law, does not work, and I suspect there will be no improvement unless HSSIP is allowed to carry out completely independent investigations that have proven that they can carry the confidence of the public, patients and clinicians. Will the Secretary of State keep an open mind about keeping HSSIP?
James Murray
I thank the hon. Gentleman for his question. I know that this is an issue that he feels strongly about, and he has raised it with me before. The Minister of State for Health, my hon. Friend the Member for Bristol South (Karin Smyth), who is taking the NHS modernisation Bill through Parliament, is leading on the changes that we are seeking to make around HSSIP and the Care Quality Commission. I hear what the hon. Gentleman is saying, but my hon. Friend has clearly set out the Government’s rationale for the changes we are seeking to making and what they will accomplish.
Marsha De Cordova (Battersea) (Lab)
I pay tribute to Baroness Amos for the report she has published, which lays bare the scale of racism and discrimination in maternity and neonatal care. This is not a surprise to anyone; it is an issue that I and many other hon. Members in this place have been raising for years. I welcome the recommendation to root out racism and discrimination in these services, but more broadly, we all know that structural inequalities exist across the NHS, whether we like it or not, and we need to hold those responsible accountable. Can the Secretary of State say a little bit more about how he intends to be held accountable in this place, and about how senior clinicians will be held accountable for their actions? We need to root out racism and discrimination.
James Murray
My hon. Friend is right to again draw attention to the importance of accountability in making maternity services operate as they should. That applies to the racism, discrimination and inequality that it is important that we tackle, as she says. Ultimately, it is right that I as Secretary of State and all Government Ministers are held to account by Parliament for our actions in this space, but we also need to make sure that accountability is spread throughout the system. Our decision to extend the anti-discrimination programme across all trusts by the end of 2027 is an important first step in making sure that all trusts are held accountable for tackling discrimination and racism where it exists. More broadly, the national action plan, which we will publish by the end of the year, will explain exactly how we will embed accountability for racism and discrimination throughout the system.
Liz Jarvis (Eastleigh) (LD)
Recommendation 3 of the report calls for improvements to how the system responds when something goes wrong, including providing a sincere apology. Will the Secretary of State apologise now to my constituents Charlotte and James, who lost their baby Norah at Winchester hospital, and to the thousands of families who have suffered the loss of a baby due to systemic failures in NHS maternity care?
James Murray
I thank the hon. Lady for her comments, and I am incredibly sorry to hear about her constituents Charlotte and James and their baby Norah. I met some of the families in Nottingham two weeks ago, and the depth of pain was numbing—that is a word that someone in the room said to me—because what was said was so heavy to hear and to understand. What made me feel even more numb was recognition that this deep pain is replicated so many times; there is also the breadth of the pain—the sheer scale of it. The hon. Lady’s constituents Charlotte and James and their baby Norah are just one more example of families being let down by NHS maternity services. The responsibility to do something about it weighs heavily on all of us, and on me as Secretary of State.
Dr Marie Tidball (Penistone and Stocksbridge) (Lab)
I welcome the Secretary of State’s statement and the work of Baroness Amos on this vital report. Disabled women are 44% more likely to suffer a stillbirth than non-disabled women. Drawing on the evidence session I chaired with our MaternAble campaign of disabled mothers, Baroness Amos’s report highlights the devastating discrimination and structural barriers that are causing such inequalities for disabled women, from devastating assumptions that we are not sexually active or capable of parenting to the lack of accessible maternity spaces and medical equipment, as well as insufficient access to British Sign Language interpreters. It sets out the appalling lack of co-ordination and continuity of care across maternity pathways and services for disabled mothers. Will the Secretary of State meet me to ensure that disabled women’s voices are central to the Government’s taskforce and in implementing the report’s recommendations to overcome the inequalities we face in our maternity care?
James Murray
My hon. Friend is an incredibly powerful advocate on the issue of the discrimination that disabled mothers face in the health service, but particularly in maternity services. She has spoken about both the discrimination and the barriers to accessing care; she is right to say that those barriers are wide and systemic, and that needs to be addressed as part of the comprehensive action plan. I would be very happy for myself or a member of my ministerial team to meet my hon. Friend to discuss this issue in more detail.
Dr Ellie Chowns (North Herefordshire) (Green)
I welcome Baroness Amos’s investigation, which has shone a light on the fact that these failings in maternity services are not isolated to one hospital or another, but exist across the piece. The Secretary of State rightly identifies that culture is at the centre of this issue, and that we must listen to the voices of women and of whistleblowers. That applies not just to maternity services, but across the NHS and, indeed, in public life more widely.
The Secretary of State has spoken about accountability starting from the top, but I noticed that he swerved the question about whether he would come back to the House to report on progress against the goals he has set himself. It is shocking and shameful that black women are three times more likely than white women to die in maternity. Will he commit to coming back to the Chamber, reporting and holding himself to account on changing those racial disparities and ensuring true equity in healthcare?
James Murray
I absolutely agree with the hon. Lady that I, as Secretary of State, must be held to account, and that is the role of this House. I will take that away and work out the best way of making sure that that happens, on a basis and to a timetable that people can understand, because I would like to make sure that I am held to account for delivering the whole action plan in the right way. I will take that point away and come back to the hon. Lady with an update.
Bell Ribeiro-Addy (Clapham and Brixton Hill) (Lab)
I, too, put on the record my thanks to Baroness Amos and her team, and to the families who relived their pain so that this report could exist—they are the real heroes here. I welcome the report, as well as the announcement of the new maternity and neonatal commissioner. It is vital that the report recognised structural racism, but that will mean nothing unless it leads to national standards that tackle inequality and deliver high-quality care for every mother and their baby.
I note that the report stops short of recommending a target to bring racial disparities in maternity care to an end. Perhaps that is because the commitment was ours to keep from our manifesto. In April, the Minister for Secondary Care told the House that the target to end racial disparities in maternity outcomes would be informed by this report’s recommendations. They have been published now, so will the Secretary of State finally give us a timetable for delivering on that target? I remind him that black women are three times more likely to die in pregnancy and childbirth, and their babies are twice as likely to be stillborn. These are not statistics; they are mothers and children who are still dying. We promised a target at the last election. Without one, we cannot measure progress, and we cannot end that disparity.
James Murray
My hon. Friend is right to draw attention to the disparity in what black women and their babies experience in the health service and the extra risks they face, particularly in maternity services. The taskforce will produce a comprehensive action plan by the end of the year, and I anticipate that it will include metrics for delivery and ways of monitoring progress. I will make sure that my hon. Friend’s comments are fed into the work of the taskforce.
Bobby Dean (Carshalton and Wallington) (LD)
To deliver on this review’s recommendations in full will require serious capital investment. Just last week, we heard that St Helier, the hospital in my constituency, was considering closing its maternity unit altogether due to potentially unsafe pipework. Will the Government commit to reviewing the phasing of the new hospital programme, or at the very least providing the funds required to keep those buildings safe and open until the delivery of a new building?
James Murray
On capital investment, I set out in my statement that we have announced an extra £41 million specifically to address critical safety issues in maternity and neonatal services. That funding is on top of the funding already in place, and it will help address those critical safety issues. The wider action plan will set out our overall approach. While funding will be a consideration in what the Government do, I again draw attention to the importance of deep-rooted issues such as culture, which must be addressed as part of the plan.
Dr Zubir Ahmed (Glasgow South West) (Lab)
I start by commending my right hon. Friend on his thoughtful and considerate approach to this investigation and other matters during his time in office. He rightly spoke about culture, and others have spoken about ideology. Does he agree that the only ideology that matters as we try to change this culture should be rooted in science and evidence?
Will my right hon. Friend therefore consider ensuring that women in maternity are the first in line to be the beneficiaries of that science and evidence, whether through the single patient record or having access to their maternity care records? That data can make sure that poor care has nowhere to hide. We need to finally get AI-enabled scanners and replace the 19th-century equipment that is currently being used to listen to babies’ heartbeats.
Finally, will my right hon. Friend share the findings of this report formally with the Scottish Government, because many of the findings on training, culture and clinical pathways will resonate there? Unfortunately, the Scottish Government have been less than forthcoming with their own investigations into this matter.
James Murray
I thank my hon. Friend for his emphasis on the need for us to tackle the deep-rooted cultural problems in maternity services. He talks about how the only ideology that we should follow should be based on science and evidence. I agree with him on the importance of science and evidence, and of making sure that women are aware of the risks and benefits of the different options available to them, so that they can make informed choices. I add that the only ideology I would be comfortable signing up to is one that says that women must be listened to. That is a principle that I think we can all agree on, and we should make sure that it is embedded in our maternity services.
My hon. Friend mentions investment in technology, including the single patient record. The single patient record can be of real benefit and make a difference, particularly in maternity services, and it will be enabled by the NHS modernisation Bill that is going through Parliament. I want to make sure that the single patient record is available to maternity services as quickly as possible. I am happy to share a copy of the report with the Scottish Government.
Alison Bennett (Mid Sussex) (LD)
The Secretary of State’s announcement of 1,000 extra midwives is welcome, even if the funding is temporary. However, this is a review of maternity and neonatal services. In Baroness Amos’s review of Sussex, she noted that in the 12 months ending in October 2025, only 50.1% of shifts at the Royal Sussex county hospital in Brighton were staffed according to British Association of Perinatal Medicine guidelines. What provision is the Secretary of State making to ensure that neonatal staffing is safe?
James Murray
I thank the hon. Lady for welcoming the additional 1,000 positions to make sure that newly qualified midwives can find a way to contribute to the NHS. She raises staffing and training, as other Members have rightly done. The taskforce will consider questions about ensuring that we have the right staffing in place, with the right training to support it, ahead of the publication of the national action plan at the end of the year.
Catherine McKinnell (Newcastle upon Tyne North) (Lab)
This report is welcome, but that does not make its existence any less tragic. Far too many mothers and babies have been failed, including mothers like my constituent Amie, who late last year was turned away repeatedly, despite reporting reduced movements. Her baby Seren was born stillborn. The NHS spends almost as much on clinical negligence payouts as it does on maternity care itself. Can the Secretary of State update us on progress made following the Lock review into clinical negligence? It is about time we started investing in better care, rather than paying out for failure.
James Murray
I was incredibly sorry to hear about my hon. Friend’s constituent Amie, who was turned away repeatedly from services despite asking for their help. We have heard that story far too many times as part of the work that Baroness Amos and Donna Ockenden have done and from our constituents. My hon. Friend is right to point out the amount of money that goes on clinical negligence, rather than making sure that services are better in the first place, which would avoid the need for clinical negligence payouts. I have met David Lock KC to discuss his ongoing work on that issue, and I will be working with him closely on it in the months ahead.
Adam Dance (Yeovil) (LD)
Yeovil hospital was included as part of the review after the temporary closure of its unit last year. Since then, families, frontline staff and I have repeatedly raised concerns with Government and NHS leaders about working culture, bullying, staffing levels and support. Today’s review backs that up, after months of feeling that our concerns have not been properly acted on. Can the Secretary of State detail what the Government are doing to improve staffing levels in rural maternity units and to address working culture, leadership, accountability and whistleblowing?
James Murray
The hon. Gentleman is right to draw attention to the impact that bullying and a poor working culture can have on maternity services. That focus on culture and on what we can do to change it will be a key part of the national action plan that the taskforce will develop. We want to make sure not only that staffing levels are correct and that staff have the right training, but that different members of staff work together across different disciplines and roles, because that is one way to make sure that the service improves.
Ian Byrne (Liverpool West Derby) (Lab)
The Secretary of State, like countless other Ministers over the years, has stood at the Dispatch Box to outline and apologise for yet another state cover-up. Can we agree that enough is enough? Will he personally intervene and beg the Prime Minister to pass the Hillsborough law in full—it has been promised to us on numerous occasions—before summer recess and end this culture of cover-ups?
James Murray
My hon. Friend is right to point to the importance of the Hillsborough law, because it will enable greater accountability and justice across society, as well as being crucial for future maternity investigations. That is why one of the commitments I made last week following Donna Ockenden’s report was to apply the duty of candour, which the Hillsborough law will enable, to all future maternity investigations, so that never again can we have a situation where senior clinical leaders choose not to participate and choose to avoid accountability.
Sarah Dyke (Glastonbury and Somerton) (LD)
A retired paediatrician and constituent told me recently that after giving 50 years’ service to the children of the NHS, she was devastated by the treatment of mothers and babies and loyal staff, whose concerns are routinely ignored, as when Yeovil’s specialist baby unit was recently closed without notice. While I welcome the Government’s commitment to a new maternity commissioner, will the Secretary of State set out how the commissioner will intervene in a trust like Somerset, rather than simply reporting on failures after harm has been caused?
James Murray
In the coming two weeks, I will be meeting the national taskforce, which I chair, to establish the scope and role of the new national maternity commissioner. I want to make sure that that is agreed with the taskforce. The taskforce will produce the action plan, which the commissioner will help to implement. I want to ensure that this is all done with the same principles in mind.
The hon. Lady also raised an important point about not only mothers being ignored, which they are far too often, but staff being ignored. A few Members have made that point today, and it bears repeating. We know that 9,000 staff contributed to Baroness Amos’s report, which underlines the fact that they want a better maternity service, too.
Anneliese Dodds (Oxford East) (Lab/Co-op)
The lack of national maternity triage standards has been of huge concern to a number of my constituents, in some cases through bitter and heartbreaking experience. The Secretary of State said that NHS England would be responsible for rolling out and monitoring triage standards. Will that responsibility pass into his Department by April next year, and how will he ensure that those standards are genuinely implemented in every trust?
James Murray
My right hon. Friend is right to point to the impact that national triage standards can make by ensuring that when there are problems, the women concerned are seen earlier and those who need support can receive it at the right time, in order to prevent greater harm from occurring whenever possible. The national triage standards are currently being set out by NHS England, because that organisation still exists. The chief executive is meeting representatives of the trust today to begin the work of rolling out triage standards across all the different trusts. When NHS England becomes part of the Department for Health and Social Care, we will of course continue to monitor that, and the taskforce will also consider it as part of its national action plan.