National Maternity and Neonatal Investigation

Baroness Pidgeon Excerpts

Monday 6th July 2026 Lords Chamber

[Lord Kamall (Con)]

My Lords, I thank the Minister for the Statement and the noble Baroness, Lady Amos, and her team for the thoroughness and compassion with which they have conducted this important investigation. Above all, our thoughts must be and are with the women, babies and families whose experiences lie at the heart of this report. Many have had to revisit the most painful moments of their lives when some want to simply move on. But after years of fighting, they must be heard. Their courage, dignity, determination and persistence place a responsibility on all of us in this House. We owe it to them not simply to listen, but to ensure that their experiences finally lead to lasting change.

Only last week the House considered Donna Ockenden’s devastating findings in Nottingham. Here, the noble Baroness, Lady Amos, presents us with a wider national picture. Once again, we see the same troubling themes emerge—women whose concerns were dismissed, staff who felt unable to speak up, inequalities that remained unchallenged, and organisations that failed to learn from previous mistakes. As Donna Ockenden herself observed, much of what is contained in this report is sadly already known to us, as it was to Governments of all political colours in previous years. That is perhaps the most disturbing and sobering conclusion of all.

The challenge before us is no longer one of evidence. We have had inquiry after inquiry, report after report and recommendation after recommendation. The challenge now is implementation. Families have every right to expect that this report will become the catalyst for sustained improvement across maternity and neonatal services. I am sure that all noble Lords welcome the fact that work is beginning immediately in a number of critical areas, including maternity triage, tackling discrimination, strengthening staffing and addressing urgent estate risks. It is right that today’s expectant mothers be given assurance and reassurance about what will change immediately, not only at the end of the year when the wider plan is due.

A few outstanding questions arise from the Statement. First, can the Minister update the House on the timetable for the Leeds and Sussex reviews? How will the Government ensure that concerns which have already been identified in those services are acted on before these reviews conclude? Secondly, it is welcome that the Secretary of State will publish the new maternity triage standards next week, but by when does the Minister expect every NHS trust to have implemented these standards and will Parliament receive regular updates on trust-by-trust progress so that families can see that improvements are generally being delivered? Thirdly, the Government propose establishing a statutory maternity and neonatal commissioner. Can the Minister explain what powers the commissioner will have to hold trusts, regulators and national bodies to account? How will local leaders remain accountable for the safety of the services that they are supposed to oversee?

The additional midwifery posts announced today are also welcome, but the report from the noble Baroness, Lady Amos, like those before it, identifies workforce pressures as a fundamental challenge to safe maternity care. Do the Government intend to address this issue immediately, or will we have to wait for the long-awaited workforce plan? If it is the latter, can the Minister update the House on when it will be published and whether it will specifically address maternity and neonatal services? I can understand her perhaps raising an eyebrow here, as she rightly and persistently challenged me on this when I was a Minister in her place.

Since the report’s publication, concerns have been raised by Dr Bill Kirkup about the removal of references to so-called normal birth ideology from the final report. Previous maternity inquiries have identified this as a contributory factor. It would not be fair of me to ask for comment on the editorial process, but can the Minister reassure the House that all relevant evidence—including from Morecambe Bay, which found that midwives were pursuing normal birth at any cost—will be fully considered?

Finally, the Secretary of State is right that culture lies at the heart of this challenge. Often, while policy changes and restructures are visible, it can be more difficult to bring about cultural change. Where the Government act with the urgency that this report demands, they will have our support. However, women and families will judge today’s Statement not by new structures, new titles or another report, but by what happens when a woman says that something is wrong. Is she heard? Are warning signs acted on? Is help from senior colleagues available when needed? Are maternity units safely staffed and can staff speak up without fear? Do families receive honesty and compassion when harm occurs? Above all, are we reducing the number of mothers and babies coming to harm?

Families have told their stories. The evidence is clear. We will support and, where appropriate, challenge the Government and the NHS as they seek to bring about this much-needed change. The Minister in the other place has made a good start, and we hope to see further progress.

[Baroness Pidgeon (LD)]

My Lords, this is another week and another traumatic and difficult-to-read report about the state of maternity services. Behind it are thousands and thousands of women and families deeply affected by these service failures. I thank them all for their contributions to this report, as well as the noble Baroness, Lady Amos.

Women are not being listened to, heard or believed, with serious consequences for safety and quality of care. Racism and discrimination are embedded throughout the maternity and neonatal system. Services are not responsive to the changing profile of women giving birth and the increase in medical interventions during birth. Antenatal, birth and labour, neonatal and postnatal services are just not joined up. From Somerset to Blackpool, the safety of having a baby has become a lottery. Women are silenced and staff who raise the alarm on unsafe care or systemic discrimination are crushed by a culture of fear. We need to see genuine accountability throughout the NHS and the investment necessary to make Britain the safest country in the world to have a baby.

I have a number of questions for the Minister. I welcome the Government’s commitment to a national maternity commissioner, but can the Minister confirm that this post will go to an independent expert and not a political appointee? Will the Minister reassure us that action will be taken before December, rather than waiting for the taskforce to report on its plans? Will the Government guarantee safe staffing at all hours in every maternity ward in the country, so that no woman has to give birth in an unsafe unit?

This inquiry has, once again, raised the issue of poor bereavement support across the NHS after pregnancy or baby loss. The national bereavement care pathway seeks to resolve this by ensuring high-quality and consistent bereavement care across the UK. The trauma of baby death and pregnancy loss can last a lifetime. Parents’ memories of the care they receive at that moment will stay with them for ever. Good bereavement care can help parents and families navigate their bereavement journey, while poor care can just add to the trauma of loss.

The first moments after a baby dies can be the only opportunity parents have to make memories with their baby, and there is only once chance to get this right. After a baby dies, parents often face really tough decisions, and they cannot make informed decisions about their baby without clear and compassionate communication from healthcare professionals. I therefore ask: will the Government roll out all five national bereavement care pathways, including for miscarriage, and actively monitor implementation across the health system? Will they ensure that suitable bereavement rooms are available in all trusts, not as a “nice to have” but as part of dignified trauma-informed care? This would be a step change for so many families.

There is so much more I could say on a topic that has shocked us all. All families, wherever they live and whatever their ethnicity, must be supported to have their babies safely. This has clearly not been the case for too many years. This is the point where things must change, and I really look forward to the Minister’s response.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)]

My Lords, we know—and we can never acknowledge it enough—that women, babies and families across the country are being harmed, traumatised and let down by a broken system. I am grateful to both Front Benches for the way in which they have received this report and for their support, and their acknowledgement of the role we have taken in government.

The noble Baroness, Lady Pidgeon, talked about trauma lasting a lifetime, and that is indeed the case. When I have met women and families who have been affected, that is what has stuck with me: the trauma never goes away. I also accept the correct challenge from the noble Lord, Lord Kamall, that the judgment will be on what has changed, not on what is written. We are very conscious of that, and I am grateful to him for reminding me of it.

Before turning to the helpful questions from the noble Baroness and the noble Lord, I will make a few comments. I too want to express my gratitude to every woman, family member and member of staff who came forward to give evidence to the noble Baroness, Lady Amos, and her team, who heard from thousands of people who showed great courage and determination to share their experiences, painful though they were, and conducted their investigation with immense sensitivity and care. The noble Baroness, Lady Amos, diligently brought together evidence from families, staff, 12 local investigations and all the past reviews, and her review shows systemic, repeated failures by our maternity and neonatal system. It has also given us the opportunity and determination to break that cycle.

As I know your Lordships’ House will agree, it is also important that we acknowledge the very positive role that so many staff and families have played in providing the necessary care.

It was most helpful that some of our immediate actions were acknowledged. But, on top of those immediate actions, some of which have been mentioned today, we have ongoing actions. We have been tackling avoidable brain injuries and maternal deaths through dedicated programmes and packages. We have already begun the expansion of Martha’s rule to all maternity and neonatal units, to give families and patients the right to request a second opinion where there are concerns.

Among other things, we have also introduced a perinatal culture and leadership programme, which is important to develop a safety culture and a learning and support culture for the leadership across all units, and an early warning system to better identify safety concerns. Importantly, because continuity of care is something that has been highlighted a lot, we are providing £10 million of recurrent funding to ICBs for this very purpose, in particular to provide midwifery continuity of care for those women who live in the most deprived neighbourhoods and who are at risk of poor outcomes.

I will do my best to answer the questions asked by noble Lords. The noble Lord, Lord Kamall, asked about the timeline for Leeds and Sussex. Donna Ockenden, who will be chairing those reviews, is currently engaging with the families on terms of reference, which will include timelines. We will not be waiting for the publication of the findings to make changes. As they emerge, those issues will be shared with us, so that we can act.

In answer to the question from the noble Lord, Lord Kamall, the new maternity triage standards will be implemented by June 2027. There must be clear board oversight in place of the operation of the triage system, including regular reviews of waiting times and actions to improve the necessary services. The role and remit of the maternity commission is being urgently considered by the National Maternity and Neonatal Taskforce. The commissioner will co-chair the taskforce, which will drive all the change as well as setting it out.

On workforce pressures, we are not waiting. There is £10.6 million investment funding in an additional 1,000 temporary roles to help newly qualified midwives to join the NHS, which is extremely important. So, we are not waiting for the 10-year workforce plan. However, the taskforce will take into consideration wider work, including the 10-year workforce plan.

With regard to concerns raised by Bill Kirkup about what is referred to as “normal birth ideology”, women have to be able to make the right decision about what is safest and best for them. No woman should ever feel pushed into a particular type of care. The words “normal” and “natural” are perhaps not particularly helpful in this setting. We are talking about vaginal births; what matters is what is best and what is safest, and I am certainly very grateful to Bill Kirkup for all this work.

The noble Baroness, Lady Pidgeon, asked further questions about the commissioner, which were helpful. The selection and appointment process will be considered as part of the process of establishing the role.

Questions were asked on action being taken before December, when the report of the taskforce will be available. As I mentioned, immediate actions are already being driven forward. These actions were already under way over the last two years and as part of the immediate response to the recommendations of the noble Baroness, Lady Amos. Where we can, we have already actioned work, and, where we need further work done, that will be developed over the next few months, at pace.

The noble Baroness raised a good point about the rollout of bereavement pathways, including for miscarriage. We are rolling out all five strands of the national bereavement care pathway. All trusts in England have signed up to implement the core standards of the national bereavement care pathway. That is relevant in this case and, across other areas of bereavement, is of particular concern.

As I draw my remarks in this section to a close, let me give noble Lords a sense of the urgency. The taskforce and its supporting expert reference groups are meeting tomorrow to discuss the findings of both the Donna Ockenden report, on which we had a Statement last week, and the report by the noble Baroness, Lady Amos. Next Tuesday, the taskforce—which is spearheading all this and chaired personally by the Secretary of State—will be meeting to discuss next steps for the action plan. To the questions from the noble Baroness, Lady Pidgeon, about the commissioner’s role, the Secretary of State has already said that he wishes that the maternity and neonatal commissioner will co-chair the taskforce with him. That would be a very welcome move.

I hope that I have dealt with the questions and, more than that, given a sense of the pace and seriousness, as well as the action that I know we all seek.