Maternity Commissioner

Anna Dixon Excerpts

Monday 20th April 2026 Westminster Hall

[Anna Dixon (Shipley) (Lab)]

It is a pleasure to serve under your chairship, Ms Jardine. I echo the thanks given by my hon. and learned Friend the Member for Folkestone and Hythe (Tony Vaughan) to all the petitioners who signed the petition, including 262 of my Shipley constituents.

My interest in maternity safety goes back to the time, over a decade ago, when I was director of policy at the King’s Fund. We set up an inquiry into the safety of maternity services, which was chaired by Baroness Professor Onora O’Neill. Despite the fact that that work was done more than a decade ago, the failures that we hear about today are sadly all too familiar. What struck us at that time was that there had been many reports in the preceding decade, including confidential inquiries into maternal and infant deaths, and that the recommendations had not been implemented. It makes me angry that there has been another decade of more inquiries and reviews, with the recommendations going unheeded.

That is why I am pleased to be an officer of the all-party parliamentary group on patient safety, and why I have worked with my hon. Friend the Member for Morecambe and Lunesdale (Lizzi Collinge) and the right hon. Member for Godalming and Ash (Sir Jeremy Hunt) to make maternity safety one of our priorities on the APPG. It has been fantastic to join colleagues, including my hon. Friends the Members for Sherwood Forest (Michelle Welsh) and for Rossendale and Darwen (Andy MacNae), across all-party parliamentary groups to share our insights and to contribute to the Amos investigation. There are still some of the same issues we heard about in the King’s Fund inquiry a decade ago: poor teamwork, weak accountability, defensive cultures and a failure to translate learning into sustained action.

Like many Members, I hear a range of stories as a constituency MP. Those are mainly centred on Bradford Royal infirmary, and I want to share the story of a constituent whose son was born with complications from the umbilical cord being wrapped around his neck. A late crash call was made after he had been delivered, but sadly he suffered catastrophic brain injury and was in a minimally conscious vegetative state. The women and her son were sent home with no diagnosis, and the child has grown up with epilepsy and other problems due to his brain injury. Sadly, it seems that midwives falsified the Apgar scores on the record and the time of the crash call. We have heard about defensive practice. We need a culture that changes it.

My constituent wrote to me:

“I have encountered significant barriers in navigating the NHS complaints system, particularly for marginalized communities. Language barriers further complicate the process, often leading to the dismissal of legitimate concerns.”

I am pleased to say that Bradford Royal infirmary has recently received good and outstanding ratings from the Care Quality Commission, for maternity and neonatal care respectively. I know that staff are not complacent about the care they give.

Others have mentioned the clinical negligence complaints system. I am a member of the Public Accounts Committee, and we have looked at how issues with that system have not only a human but a financial cost. One of our conclusions was that patients often pursue legal action because the complaints system itself is so confusing and unresponsive, which echoes the thoughts of my constituent. It is therefore vital that there are timely apologies from clinical staff and that we put in place effective, compassionate local resolutions. That will reduce claims, but is also ethically the right thing to do.

I would be grateful if the Minister could update us on the progress of the David Lock KC review, which we heard a lot about at the Public Accounts Committee. Alongside a better complaints system, we also talked about reform of litigation and potentially a no-fault compensation scheme, which would certainly go some way to creating a better environment. At the moment, families often experience long legal battles following harm, which leads to clinicians and organisations becoming defensive.

I want to finish with a brief example of what happens when people are failed but want to share any learnings with the NHS. My friend Martha’s second child died. It was a homebirth with complications. She started labour at 2.30 am. At 5.30 am she called the delivery suite, and staff told her to call back in a few hours. When she did, they sent out a midwife team who did not reach her until 9.40 am. A few moments later, her waters broke and she gave birth to her second daughter, but there was meconium in her discharge. As Members who are clinical will know, that is a sign of baby distress. The midwives called an ambulance immediately. It was another 19 minutes after the 999 call until the ambulance arrived and oxygen was given. Those minutes after birth were crucial, and that length of time without oxygen would have caused global brain damage and severe disability had their daughter survived. Sadly, she died in the care of Great Ormond Street hospital just a couple of days later.

The point of telling that story is that there are many missed opportunities to provide safer care. If the midwives had carried birthing equipment when they were attending, they could have provided immediate care. If the ambulance had prioritised the call from the midwife, it could have prevented the deterioration.

[Helen Maguire (Epsom and Ewell) (LD)]

Will the hon. Lady give way?

[Anna Dixon]

I am sorry but, respectfully, I am not going to give way.

If the ambulance had routinely carried a neonatal meconium aspirator, that could have prevented the death of my friend’s daughter. My friend said:

“I was not told who we could complain to following these experiences, or when we should do so.”

Whether it is through a maternity commissioner or another way, we need to learn systemically from women’s experiences so that safety recommendations can be implemented. When we hear from Baroness Amos’s investigation, I hope that Ministers will finally act swiftly to implement her recommendations and back them up with investment, so that families can have confidence that when tragedies like those of my friend and those of my constituent occur, the system will genuinely learn, improve and take action.

[Christine Jardine (in the Chair)]

I call the Liberal Democrat spokesperson.

--- Later in debate ---

[The Minister for Secondary Care (Karin Smyth)]

It is a pleasure to serve under your chairship, Ms Jardine. I thank my hon. and learned Friend the Member for Folkestone and Hythe (Tony Vaughan) for responding so ably on behalf of the petitioners. That thousands of people wanted us to talk about this subject, many of whom will be watching—many are in the Public Gallery—demonstrates how important the issue is and how it touches so many of our constituents. I am grateful to my own constituents for signing the petition.

I place on record my thanks to Theo Clarke, who is also in the Gallery, who did a lot of work in this area when she was an MP, based on her own experiences. I agree with the hon. Member for Sleaford and North Hykeham (Dr Johnson) that, by detailing injuries and raising some of the taboos, she did a great service to other women. I also thank Louise Thompson, also in the Gallery, for the time and effort that she has put into campaigning for improvements in maternity care following her own experiences. All the organisations that work on behalf of women, bringing forward their stories to national attention, do a great service—it is not an easy thing to do, and we thank them for it.

The hon. Member for Esher and Walton (Monica Harding), and my hon. Friends the Members for Morecambe and Lunesdale (Lizzi Collinge), for Altrincham and Sale West (Mr Rand) and for Shipley (Anna Dixon) all highlighted their constituents’ experiences. To be clear, the Secretary of State leads on this work directly, and a meeting has been set with Louise and Theo to discuss the issue of a maternity commissioner more thoroughly. I encourage both Theo and Louise to continue to engage with the national investigation chaired by Baroness Amos. Their campaigning, along with that of so many others, has led the Secretary of State to directly provide the leadership himself, ensuring that the issue gets attention. We look forward to Baroness Amos’s recommendations.

As many Members have said, the vast majority of births are safe, and there are some outstanding examples of care in the NHS. But where things do go wrong, it can have a devastating impact on women and their families, who are at their most vulnerable when giving birth. We are fighting systemic issues, entrenched inequalities in maternity care, a failure to learn from mistakes, and culture and leadership issues.

It is appalling, as we have heard again in this debate, how in the 21st century in Britain there could be such a difference in outcomes for mothers from different ethnicities and for those from deprived backgrounds, not least in constituencies such as mine. That was a point ably made, as ever, by my hon. Friend the Member for Clapham and Brixton Hill (Bell Ribeiro-Addy), who, in leading the APPG, does an amazing amount of work to highlight the issue. I confirm to her that we remain committed to setting a target to close that mortality gap, and will be informed by Baroness Amos’s recommendation. The issue of deprivation and ethnicity differences was also raised by my hon. Friends the Members for Rochdale (Paul Waugh) and for Worthing West (Dr Cooper). That issue is why the Secretary of State has launched the national investigation into NHS maternity and neonatal care, chaired by Baroness Amos. She is bringing together the findings from past reviews and local rapid reviews, and new evidence from families and staff, into one clear national set of recommendations.

As my hon. and learned Friend the Member for Folkestone and Hythe said, previous issues and scandals have produced many recommendations, including, as we have heard, well over 700 recommendations on maternity care since 2015. As my hon. Friend the Member for Shipley reminded us, some of the information from those investigations has been available for well over a decade.

We know what needs fixing, but changes to processes and procedures here and there are not enough. There is a risk that some recommendations might fix the symptoms, but not the underlying causes. Many colleagues have talked about culture. I agree with my hon. Friend the Member for Rossendale and Darwen (Andy MacNae): we cannot keep going round in the same cycle. There is an underlying cultural issue, and systemic change needs to happen. I commend my hon. Friend for the work that he does on the APPG and for sharing the loss that he and his family suffered. That loss is informing that work.

My hon. Friend the Member for Mansfield (Steve Yemm) also talked about that culture and the need for deeper questions. Other Members talked about the need to speak up. I agree with my hon. Friend the Member for Morecambe and Lunesdale, who highlighted the importance of that culture of encouraging people to speak up.

[Anna Dixon]

Does the Minister agree that training obstetricians and midwives together as a team is an important part of creating that unified culture that we know is so important to underpin safety for mothers and babies?