Oral Answers to Questions
Lee Anderson Excerpts(1 month, 1 week ago)
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Stephen Kinnock
I am not sure if the right hon. Gentleman was listening to my previous answer. We have just set out a groundbreaking piece of legislation to settle the issue of adult social care pay, which is more than the last lot did in 14 years. We are absolutely committed to building cross-party consensus. We know that we need a process that will be sustainable and fix adult social care for the long term. That absolutely includes engagement and dialogue across this House, because we want to build a consensus that works. We recognise that successive Governments have failed to get a grip on this issue, but we recognise the vital role that adult social care will play. It is going to be a hugely important part of our 10-year plan for the future of the NHS, and I look forward to engaging with all hon. Members on this issue.
Lee Anderson (Ashfield) (Reform)
The Parliamentary Under-Secretary of State for Health and Social Care (Andrew Gwynne)
I thank the hon. Member for raising awareness of this important issue. He has spoken powerfully about the experiences of patients in his constituency and his wife’s personal battle with sepsis. The long-term complications of sepsis can have a devastating impact long after discharge from hospital. Through the National Institute for Health and Care Research, the Department is funding research to improve outcomes for sepsis survivors.
Lee Anderson
Last year, Abbi Hickson from Ashfield lost both her hands and her lower legs to sepsis. The local hospital was very slow to diagnosis her condition, and since then she has been suffering from shortness of breath, fatigue and a lack of sleep. This could be post-sepsis syndrome, yet nobody at the hospital has spoken to her about it. Does the Minister agree that every single sepsis patient and survivor should be advised about this condition?
Andrew Gwynne
I absolutely do, and I pay tribute to Abbi, a beautiful woman whom I was privileged to meet after the Westminster Hall debate last week. Although care after sepsis will vary hugely on a case-by-case basis, we need to make sure that the needs of each individual are met. In this case, it sounds like they have not been met. If the hon. Gentleman wants to meet me to discuss this issue further, I am more than happy to do so.
Sepsis Awareness
Lee Anderson Excerpts(1 month, 2 weeks ago)
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Lee Anderson (Ashfield) (Reform)
I beg to move,
That this House has considered sepsis awareness.
It is a pleasure to serve under your chairmanship, Sir Christopher. Sepsis is one of the least well known medical conditions and the No. 1 cause of preventable death in the world. Eleven million people die each year in the world from sepsis, and that represents one in five of all deaths in the world. Sepsis can be very difficult to detect and hard to distinguish from other illnesses. Sepsis claims more lives than lung cancer, bowel cancer, breast cancer and prostate cancer put together. That is truly astonishing. Across the UK alone, 48,500 people a year die from sepsis. The Academy of Medical Royal Colleges suggests that the figure is much higher—about 68,000 a year. That is incredible.
Given that there are approximately 200,000 cases of sepsis each year in the UK, it costs the NHS between £1.5 billion and £2 billion every single year and the wider economy at least £11 billion a year—some people think the figure is closer to £15 billion. The direct cost of sepsis to the NHS is 1% of its budget.
One reason why I requested this debate today is that I have many constituents who have been unfortunate enough to suffer from sepsis. I have a very brave young lady in the hall today. That is Abbi; she is sitting at the back. I am incredibly proud of the strength and determination she has shown to overcome this illness—she is a survivor. I will tell Abbi’s story. On 28 November 2022, she had been to her doctor’s for some antibiotics for her tonsils, because she was a long-time sufferer of tonsillitis and thought it was tonsillitis again. She had suffered with that all her life, so that was understandable. At 6 pm on that day, she was blue-lighted to King’s Mill Hospital in Ashfield, to the accident and emergency department, because she was fighting for breath and literally dying in front of her husband, Steve, who was sat there. She was given numerous injections of adrenaline while travelling to the hospital, because it was thought that she was having an anaphylactic fit and it was a reaction to the antibiotics that she had had that morning. When she arrived at A&E, she was put on 10 litres of oxygen by the staff, but it was evident that that was not enough; it was not doing the job. But they did not, unfortunately, administer any antibiotics or put her on IVs at that time; no blood tests were taken. Her husband, Steve, was constantly asking the staff, “Is there something else we can do for Abbi?” Only now, looking back a few years later, is it clear that sepsis was never thought of at the time.
Abbi very quickly deteriorated, so she was transferred to the intensive care unit at King’s Mill Hospital, where she was placed in an induced coma. She was fighting for her life, and all her organs began to shut down at a very rapid rate. Only when the ICU did some tests, when the results started to come through, did staff realise how ill she was and that she had actually got pneumonia, strep B and sepsis.
However, that was just the start of Abbi’s journey. When the ICU team realised that the situation was far more complicated than they could deal with at King’s Mill, they contacted Glenfield general hospital in Leicester. She was transferred there to be placed on an ECMO machine, which takes the place of the heart and lungs—I suppose it is a life support machine. She was lucky to have fitted the criteria to go on that machine. She stayed on it for the next three weeks, in a coma and fighting to stay alive. Without it, she would not be here today. There are only five of those machines in the UK, and it costs the NHS £20,000 per day, per patient. While she was on the ECMO machine, it was visible to Abbi’s family that she would lose both hands and both legs beneath the knee, because sepsis had taken over her body and given her gangrene.
On 17 December, Abbi was transferred back to the ICU at King’s Mill hospital because she no longer had to be on the ECMO machine at Leicester, but she still needed round-the-clock intensive care treatment. On 9 February, she was transferred to the burns and plastics ward at Nottingham city hospital, where she would wait for her amputations. Imagine that—having to wait in hospital knowing that they were going to take her arms and legs away, after everything she had been through. On 4 May, she was discharged after spending six months in hospital, coming out as a quadruple amputee. She told me just before the debate began—she sometimes forgets—she also lost the sight in her left eye. Incredibly sad. Incredible, brave lady. That is Abbi’s story, and I thank her for sharing it with me.
Other constituents have contacted me about sepsis, including Karen from Ashfield. Her elderly mother contracted sepsis and had an awful time at the hospital. Her diagnosis was slow. It was not picked up properly, and, just a few months later, she sadly collapsed and passed away. Neil from Ashfield was much luckier. It was picked very quickly. They got the antibiotics into his body and he made a full recovery. With Pam from Ashfield, it was lucky for her husband that she was a former nurse. She recognised the symptoms and insisted that the hospital put the IV antibiotics into his body very quickly. There is a window of about 12 hours to get the antibiotics in. The point of today’s debate is to get the awareness out there, not just in the wider community but in hospitals, because it is very unfortunate that sepsis is being missed. Maybe if they had picked it up quicker in Abbi’s case, we would not be sat here—I do not know. Shirley from Ashfield had a better experience. The hospital picked it up very quickly and she made a full recovery, so there are people making full recoveries.
We all know about the sad story of our colleague, Craig Mackinlay—Lord Mackinlay now. I have had conversations with him over the past few weeks about this debate, although he could not be here today. He had a torrid time. His wife was told he was going to die, but he fought back. I think she put pictures of his family on the ceiling of his room at the hospital. He is a fighter, is Craig. It nearly took his life and it has taken him several months to get over it. We did not know where he was; we thought he was just on holiday somewhere at first. We did not see him for months and then we heard what condition he was in. He came back to Parliament a few months back. I will be honest: there was not a dry eye in the House when he walked in as the bionic man. It was so emotional. He is living proof that we can fight back from this disease and have a reasonable quality of life, given the right support and a good hospital.
As I have said, 48,500 people a year die from sepsis. Other organisations put that figure much higher. That is almost 1,000 people a week dying from sepsis in this country, but if somebody was stopped in the street and asked what it was, they would probably struggle to say. The symptoms are a very high or low temperature, uncontrolled shivering, confusion, passing less urine than normal, and blotchy or cold arms and legs. I know that because a few years back, my wife had those symptoms. My wife has cystic fibrosis and she is post double lung transplant, so she has all sorts of medical problems as well, and we thought that it was maybe a rejection of the lungs or pneumonia. We managed to get her to the hospital, and it was sepsis. They told us at the hospital that if we had left it any longer, she would have died—simple as that—because of other complications and she has no immune system. Last year, when she had it again, we knew straightaway what it was. She had the same symptoms, so we got her there pretty sharpish.
I also learned today from Abbi that, on her road to recovery she got her prosthetic limbs but she is also—I do not know if the Minister is aware of this—on a list at Leeds hospital to have a hand transplant. She has a prosthetic for her right arm, but she is on the list for a hand transplant—it is absolutely amazing that we are doing that now. It offers people a lot of hope—Abbi does not stop smiling. We have a campaign in this country for strokes and we all know the symptoms now. We have all seen the stroke campaign on TV about the facial symptoms or someone not being able to talk or keep their arms up. We know all that now. I would like to see a campaign for sepsis so that families and, more importantly, our hospitals are fully aware. What does it cost to give somebody some antibiotics as a precaution if they are shaking, are cold, are blotchy and have a fever? For goodness’ sake, what does it cost to put an IV on them and get some antibiotics pumped into them while they do the other checks?
Helen Grant (Maidstone and Malling) (Con)
I congratulate the hon. Gentleman on securing this important debate. Does he agree that sharing the stories of all those we know who are affected by sepsis, as he has done so sensitively today about his Abbi, helps to highlight the importance of early recognition of this dreadful disease and the importance of early diagnosis?
Lee Anderson
The hon. Member is absolutely right, if I am honest, and that is what this debate is about. It is about sharing stories. As I said earlier, we could probably ask 100 people on the street what sepsis is and the vast majority would struggle to tell us what it is and what the symptoms are. What we need, and it is quite right, is a campaign for awareness, whether that is through schools or on social media or the TV. I would really like to see a campaign on sepsis so that everybody knows the symptoms. I am going to wrap up now—I have spoken for 13 minutes. I know there are lots of colleagues present who want to speak as well and I am conscious that we have only an hour.
Lee Anderson
I thank every hon. Member here for making some wonderful contributions and sharing some stories. I think the hon. Member for Kingswinford and South Staffordshire (Mike Wood) summed it all up perfectly: “Could it be sepsis?” That is the question all health professionals and families should be asking themselves if they see the symptoms.
It has been a wonderful debate. Once again, I thank Abbi and Steve for coming here, because it is real-life stories such as Abbi’s that inspire us as MPs to tell them in this place. If we cannot do anything about sepsis awareness, such as having a campaign, I would be very disappointed. However, I have been very encouraged by what the Minister has said today, and by fellow Members from all parties. All I can say to sum up, Sir Christopher, is, “Could it be sepsis?”
Question put and agreed to.
Resolved,
That this House has considered sepsis awareness.
Preventable Baby Loss
Lee Anderson Excerpts(2 months, 3 weeks ago)
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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—
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.
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.
Oral Answers to Questions
Lee Anderson Excerpts(4 months ago)
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Wes Streeting
I am delighted to welcome my hon. Friend to his place. I am personally grateful to the Royal Free hospital for saving my life when I went through kidney cancer. NHS waiting lists stand at 7.6 million, which was still rising as this Government took office. Our 40,000 extra appointments, scans and procedures and our doubling of the number of diagnostic scanners will make a real difference to getting that backlog down to where it should be.
Lee Anderson (Ashfield) (Reform)
During the general election campaign, the Health Secretary visited King’s Mill hospital in Ashfield, and I am sure that helped me to get re-elected. King’s Mill was built on a private finance initiative deal by the last Labour Government and is going to cost £3 billion for a £300 million hospital. Will the Secretary of State please now assure me and the people of Ashfield that this will never happen again?
Wes Streeting
Despite my best efforts, the hon. Gentleman is back. I congratulate him through gritted teeth.
I was very impressed by what I saw at King’s Mill hospital, and I am proud of the last Labour Government’s record of delivering the shortest waiting times and the highest patient satisfaction in history. As I said during the election campaign, we will build on that success and learn from some of our shortcomings, too.