Ockenden Report

Baroness Watkins of Tavistock Excerpts

Wednesday 30th March 2022 Lords Chamber

[Lord Kamall (Con)]

I begin by thanking the noble Baroness, Lady Finlay, not only for her questions today but for the advice she has given me over a number of months since I started in this post. I have learned so much from the noble Baroness, especially from her courage to speak about her own professional experiences and admit where there are issues that need to be addressed. I am very grateful for that.

I completely take the point about working together from day one because, if you do that, you embed that culture of collaboration from day one, rather than just training people and then saying, “Oh, by the way, don’t forget to work collaboratively”. I think that has to be bred into the system and it is something we have to understand.

The other principle, which all noble Lords discussed in debates on the Bill, is the concept of a safe space. In an ideal world, we would find out who was responsible and they would be held to account, but what is really important is that we learn from that and the system learns from its failures. We have to encourage the ability to have a safe space where people feel confident about speaking up. We saw incidents where people felt bullied into not speaking up or where they withdrew their statements. If we can get this through the SHA and throughout the culture of the new HSSIB, this would be a really important first step. I thank noble Lords who, during the debate, pushed for the removal of certain bodies in order to make sure people felt comfortable coming forward.

On the CQC, there are real questions about the inspections in 2014 and 2016 and why it did not recognise safety concerns at the trust. Subsequently, the CQC did recognise the issues and place the trust in special measures. There was some progress made by the trust following this, and there were two subsequent visits. As a regulator, the CQC holds providers to account and makes clear where improvements must be made, but I think it recognises that there are lessons to be learned. There are lessons to be learned not only in government but across the health and care sector. It is important that we look systemically at how we work together and address some of those concerns.

[Baroness Watkins of Tavistock (CB)]

My Lords, I also thank the Minister for the sensitive way in which he has addressed this very difficult statement.

I was particularly moved by the fact that there are empty bedrooms. I have a daughter who is 31. I took a long time to get pregnant and, at the very end of my pregnancy, I woke up and said that I was ill. I went to hospital and my husband said to me, “I don’t think you’re ill, I just think you’ve never had a baby before”. But as the day went on, he came to see me, and apparently I said to him, “If anything happens to me, you will look after our child, won’t you?” He said it frightened him because I am not given to drama. He went to the midwife in charge of the ward and said, “I’m really worried about my wife”. It was taken seriously. I had a scan, and—the noble Baroness, Lady Finlay, will know that this is very rare—I had a rare form of pre-eclampsia in my liver, called HELLP syndrome. In 10 minutes, I had a caesarean section. I was ill for several months and my daughter was in ITU. She has a bedroom at home—she does not live in it except when she comes back—and it has really made me think, not just about the women who lost families but about how much we train healthcare professionals to listen to the significant other of the person. We have not said a lot about that today. That significant other may be a husband, it may be a man, it may be a same- sex partner, but I urge that training includes listening to the significant other.

I also want to raise that strengthening clinical reporting at board level is essential. I and others did research after the Francis report, where it was very clear that boards were not spending significant time looking at clinical issues but were looking at financial issues. That changed then, but I believe the Ockenden report reminds us that there should be further NHS guidance to boards about their responsibility for examining mortality and morbidity rates in order that that is kept closely under supervision at board level. Believe you me, as an ex-deputy chair of a trust, I know that that was one of the most important things I looked at. I chaired the clinical audit committee and I know that those are the things that can pick up recurring issues early and enable boards to look at what is actually going on in the system. We do not want to have another Ockenden report that may not be about midwifery but about something else.

My final issue is to re-emphasise that we must get workforce planning right for the whole of the NHS, not just midwifery—though I welcome everything the Minister has said in relation to midwives and obstetricians.

[Lord Kamall (Con)]

I thank the noble Baroness, Lady Watkins, for sharing a very personal story. It must have taken quite a bit of courage to share that with us so publicly.

The noble Baroness talked about the “significant other”. Sometimes we consider ourselves the insignificant other. I remember when I became a father about 20 years ago for the first time. When you watched the TV programmes, they quite often told the father, “Go and have a smoke and come back. We’ll let you know.” Clearly, nowadays, you would not advise anyone to go and have a smoke. I remember how involved I was allowed to be. I was in the room for 22 hours for the first birth. Pre-natal care was fantastic, but once the baby was born, my wife was ushered into a bathroom, and I was sent away somewhere else. I could hear her voice. She called me. When I went in, she was sinking into the bath; she was just too exhausted. She was terrified and did not have the strength, and I pulled her out. It might have been a tragedy—I do not know—but it shows that even little things like that could have made a huge difference.

We are all grateful when a wonderful new life comes into this world. Let us think about the preparation that families go through—they prepare a separate room; families buy baby clothes and toys for everyone, expecting that bundle of joy to come home. When that is cruelly snatched away from them due to incompetence, we have to make sure that it happens as little as possible in the future. We know that incidents will occur. It brings a lump to the throat.

Noble Lords will recognise that there has been a debate on workforce. There is a debate in government on it. We shall just have to see how that resolves itself. I have heard loud and clear from noble Lords that it is not only about the maternity workforce; it is also about the wider NHS workforce, as well as making sure that we learn from incidents like this and build in that culture of prevention but also openness when things go wrong.