Cumberlege Review: Pelvic Mesh

Debate between Sharon Hodgson and Sarah Green

Thursday 5th December 2024 Westminster Hall

[Sarah Green (Chesham and Amersham) (LD)]

It is a pleasure to serve under your chairmanship, Mr Stringer. I thank the hon. Member for Harlow (Chris Vince) for securing today’s debate. We are here because four years after being published, the Cumberlege review has not been implemented and there is still no redress scheme. I will turn in more detail to the progress made on those recommendations, but first I pay tribute to the many individuals who have campaigned so hard for so long to be heard, for their experiences to be taken seriously, to receive some sort of justice, and to know that the same harm will not be done to others. Some of them are in the Public Gallery today and I thank them for their tireless campaigning.

I also pay tribute to the right hon. Member for Godalming and Ash (Jeremy Hunt), when he was Health and Social Care Secretary, and to the former Member for Maidenhead, when she was Prime Minister, for commissioning the review in the first place in February 2018. Baroness Cumberlege has never stopped giving voice to those she encountered during the two years she led that review. She has gone to great lengths to keep this issue on the agenda. She is due to retire shortly and we will miss her. I would like to say how grateful I am, as I know others will be, not just for her advocacy on this issue but for her encouragement and support of hon. Members in this place to do the same. If I may be so bold, Baroness Cumberlege has played her part. It is now up to us in this place to hold this new Government to account and to ensure that her recommendations are implemented in full.

Let us not forget that the Cumberlege review was called “First Do No Harm”, because at its centre are people who suffered avoidable harm—harm done to them by our health system. I was first introduced to this issue by my constituent Carol. I have shared her story before and remain in awe of her dignity and desire to help others despite having experienced the most devastating medical trauma. She needed her MP to help her get a visa for the United States for urgent medical treatment during the pandemic because of the travel restrictions that hon. Members will remember. She had undergone a hysteropexy and a rectopexy using surgical mesh.

Instead of resolving Carol’s pelvic organ prolapse, the procedures left her with a serious autoimmune disease, struggling to walk and unable to continue her normal daily life. She had to take long-term sick leave from her job as a doctor and could not remember a day without pain. When she contacted me for help with her visa, she was seriously unwell and had been told that she urgently needed her mesh removed or her prognosis was not good. We managed to get her the visa she needed. She is now mesh-free following a successful removal, and she is the first person in England to have undergone successful rectal mesh removal. She is still suffering, but is no longer in the same danger that she was. She is clear that she was able to look outside the NHS and the UK only because her medical training and personal resources enabled her to find Dr Veronikis, who treated her successfully. I should say at this point that there needs to be more awareness of rectopexy mesh, which affects men, women and children.

Carol and others like her were given hope when the Cumberlege review was initiated, and again when it was published in July 2020 with its nine recommendations. I am sorry that to say that not enough progress has been made on those recommendations since. The reality is that only two of the nine recommendations have been implemented in full. The first was an apology, which was given as soon as the report was published. The second was to establish the office of the Patient Safety Commissioner.

Beyond that, things have stalled. Recommendations 3 and 4 called for an independent redress agency, and for redress schemes to be established for all three interventions. After originally rejecting those two recommendations, the Health Minister at the time asked the Patient Safety Commissioner in late 2022 to look at the options for providing redress for those who had been harmed by mesh and valproate. The commissioner’s report—the Hughes report—was published in February. I was present at its launch, and it really felt like a milestone; it felt as though progress had been made. Surely the Department would not commission that work if it had no intention of following through on a redress scheme.

That was in February this year. By the summer, when the election was called, the previous Government were still saying that they would respond to the report, so they never gave a formal response. To date, there has been no official response from the new Government to the Hughes report. In the words of the Patient Safety Commissioner:

“it is now urgent for the government to give those families some clarity. Many of them live with pressing financial hardship, as well as physical pain and disability…we must not compound the physical and mental harms experienced by these families by setting and raising false expectations if there is no intention to deliver on redress.”

[Mrs Hodgson]

I am grateful to the hon. Lady for covering the recommendations, which I was not able to do. That has relieved me somewhat. We have at last seen some compensation for the victims of Windrush, the infected blood scandal and the Horizon scandal. Does she agree that it is incumbent on the Government to treat this scandal with the same seriousness, fully accept recommendation 4 and put the redress scheme in place?

[Sarah Green]

I could not agree more. This is where I must pick up Carol’s story again. She tried to pursue her claim against her original surgeons through the courts, and she hit on an unexpected problem. She approached multiple legal firms who would not take her case because one or both of the surgeons were advising them on other cases and, as such, it would have been a conflict of interest. Indeed, the same surgeon who caused Carol life-changing injuries acted as an expert witness in an unrelated surgical mesh negligence case. The judge in that case said:

“he had cherry-picked those parts of the evidence which were supportive of the Defendant’s case and did not comment on those parts which were consistent to the Claimant’s. That is not the correct approach to be taken by an independent expert, whose duty is to the court. His evidence lacked balance and was unpersuasive.”

On this occasion, the judge called it out, but that is not the only instance of the medical profession closing ranks—it is not a unique occurrence. Such clear bias and conflicts of interest are a huge barrier to justice for mesh victims around the country.

The point of recommendation 3 in the Cumberlege review was to establish a non-adversarial avenue for redress after someone has been harmed in a healthcare setting. Both the Hughes report and, more recently, the Darzi report found that the current clinical negligence system is difficult for patients to navigate and prevents the healthcare system from learning from its mistakes. It is also eye-wateringly expensive for the taxpayer. If it is the dead hand of the Treasury blocking a redress scheme, Ministers would do well to reflect on that. As the Patient Safety Commissioner points out, the clinical negligence system is behind only nuclear disarmament and pensions on the list of liabilities on the Government’s balance sheet. I must ask the Minister when the Department will respond to the options outlined in the Hughes report, and when families can expect to see redress schemes up and running.

Recommendation 5 relates to the establishment of mesh centres around the country, and while such centres have been established, they get mixed reports from patients. My question on the mesh centres is about their outcomes. How is the Department ensuring a consistent service across them all, and how are outcomes being measured? With so many people reporting dissatisfaction with the centres, it is not enough that they exist; they need to be working well for the patients they are there to serve. Recommendation 6 relates to the MHRA, and it is clear that we still need the yellow card reporting system to improve. I would also welcome the Minister’s thoughts on progress against recommendation 7, which is about creating a central patient-identifiable database. To my understanding, it is still a work in progress.

The previous Government’s decision not to take forward the eighth recommendation, which is for a mandatory register, is disappointing. The recommendation called for

“Transparency of payments made to clinicians”

and

“mandatory reporting for pharmaceutical and medical device industries of payments made to teaching hospitals, research institutions and individual clinicians.”

I fail to understand why more progress has not been made on that. I know that campaigners have written to the Department asking it to consider a sunset Act that speaks to that recommendation, and I urge the Minister to chase a response to them.