Ockenden Review

Baroness Thornton Excerpts

Monday 14th December 2020 Lords Chamber

[Baroness Thornton (Lab) [V]]

My Lords, I first declare an interest as a non-executive director for a London hospital trust. I thank the Minister for the debate today. This is a harrowing report, and the latest in a series of reports over recent years. It follows on the heels of the Morecambe Bay report, and we know that the East Kent report was launched earlier this year to investigate 54 babies dying between 2014 and 2019.

I first congratulate Donna Ockenden on this interim report. As she rightly says in her letter to the Secretary of State,

“we want to bring to your attention actions which we believe need to be urgently implemented to improve the safety of maternity services at The Shrewsbury and Telford Hospital NHS Trust as well as learning that we recommend be shared and acted upon by maternity services across England.”

The scale of the findings in this interim report is distressing in the extreme. The relentless campaign of parents Rhiannon Davies and Richard Stanton, and Kayleigh and Colin Griffiths, must be recognised, and we must pay tribute to and thank them. At a time of greatest grief—the loss of a baby—they have done something vital to ensure that other parents do not suffer the losses they have.

Babies suffered fatal skull fractures from forceps use; women were left screaming in agony for hours; infants developed long-term disabilities as a result of terrible maternity care. There were baby deaths, high maternal deaths, and a catalogue of incompetence, neglect and cruelty. There was failure to handle high-risk cases correctly, an overzealous pursuit of natural, vaginal births leading to a reluctance to perform caesarean sections, and inadequate consultant supervision. Struggling mothers were mocked and called lazy. Mothers were blamed for their baby’s death. Parents were not listened to; legitimate questions were not responded to and blocked; responsibility was not taken.

There was poor assessment of risk and no discussion of risks with mothers. Practice in assessing ongoing risk was poor. Escalating problems were spotted too late, leading to delay in transfer to hospital and death. There was poor ability to spot the refusal to acknowledge. Escalation was seen by midwives as a slight on their ability, not a prudent response to risk. As bad was the internal culture which allowed this to carry on without proper, effective management or regulatory oversight. There were adversarial attitudes between doctors and midwives. Perhaps the Royal Colleges need to talk to each other about the lack of mutual respect for their particular expertise and experience, and the value placed on these.

This is an interim report because Ockenden is rightly concerned that change needs to start immediately. One hopes that it has already been happening in the trust, rather than waiting for the full report and for the Government to take time to consider it. That might literally cost lives. It might mean more babies suffering damage, which means disability for the whole of their lives. This concerns not only deaths but sometimes severe disabilities, which cause huge suffering for the child and have a huge impact on and cost for their families and, indeed, for the state.

It is now clear that the Ockenden review will be far larger and take far longer than was originally intended. Can the Minister assure the House that the review has the resources necessary to complete the final report as soon as possible? There are seven immediate and essential actions outlined in this interim report. What progress is being made to implement these recommendations? What actions is NHS England taking to implement these interim recommendations across England? The turnover of leadership at board and officer level in this trust was surely a warning sign that something was amiss. Why was there not earlier support and intervention by NHS England? I know how appointments are made at senior level; they have to be signed off by NHS England. It must have known. What happened? One needs to ask the same questions of the CQC, both in terms of leadership instability at the trust and why the glaringly obvious warning signs of infant and maternal death were not acted upon sooner.

More broadly, can the Minister explain what action is being taken to ensure that there are enough staff in all maternity units? Perhaps the Government can, this time, commit to legislating for safer staffing levels. What is being done to tackle the current estimated 3,000 midwife vacancies?

Finally, for the vast majority of us who give birth in NHS hospitals, it is a wonderful experience, and a very safe one. We want that to be available to all women.

[Lord Scriven (LD)]

I declare an interest, as my husband is a medical director for NHS England, but not in the region where this hospital is located.

From these Benches, I want to start by sending our heartfelt love and admiration—as, I am sure, do many across the House—to those parents and families who will have an empty place in their home this Christmas, due to the poor care they received at Shrewsbury and Telford Hospital NHS Trust maternity services. This report is distressing and shocking to read. It is hard to comprehend that it describes a care system in this country, in this century. It describes everything from the lack of basic things like human empathy, compassion and support, to poor medical practice and lack of carrying out best practice and adhering to agreed professional standards. This has led to grief, long-term disability, lifelong complications and the unnecessary deaths of newborn children and mothers.

This is not the first case of poor practice in maternity care that has come to light after brave families and parents have refused to be cowed and silenced. Morecombe Bay should have been a wake-up call for ensuring that systematic, integrated changes took place. It is clear that cultural and systematic change at scale and in depth has not happened, despite previous warnings. The healthcare regulator this year reported that four out of 10 maternity services do not meet the safety threshold of care. I ask the Minister why, in 2020, that is an acceptable statistic.

In 2017, the £8.1 million national maternity training fund was withdrawn. Does the Minister now, in hindsight, regret this, and will he seek to re-establish this fund urgently? Will the Minister inform the House who is responsible—politically and managerially—within NHS England for ensuring that, this time, the changes highlighted are implemented, particularly in the seven areas seen to be urgent? What is the timetable for implementing the seven immediate and essential actions required across the NHS? What resources will be allocated to implement the 27 local and 7 immediate and essential actions required?

This must not be another report that gets sympathetic words from those with political and managerial responsibility but then ends up on a shelf gathering dust. That is why the Minister needs to outline a timetable for implementation, what resources will be allocated and who, ultimately, is accountable for ensuring that the systematic, deep changes happen, so that no family has to deal with the kind of grief and trauma that so many families in this report have had to deal with.