Ockenden Report

Baroness Walmsley Excerpts

Wednesday 30th March 2022 Lords Chamber

[Baroness Merron (Lab)]

My Lords, I thank the Minister for bringing this Statement to your Lordships’ House and for the reassurances he has given and the actions that have been, and will be, taken. I listened to this Statement in great sadness and shock, as I know that so many others have as they heard the news unfold. I will start by expressing heartfelt gratitude to the families who came forward. We would not be here today had it not been for their persistence and the resilience they have shown across over 20 years in their fight for justice. I also thank Donna Ockenden and her team for this landmark report. I utterly regret the appalling circumstances in which it has come before us.

Today marks an important milestone for hundreds of bereaved families who are seeking justice. As the Minister said, it is not the end, because West Mercia Police are investigating some 600 cases. This report lays bare the disturbing truth of what families have had to face and why their fight for justice has been so fierce. The inquiry examined cases involving nearly 1,500 families in instances crossing over decades. It concluded that hundreds of babies were stillborn, died shortly after birth or were left severely brain damaged, and that mothers died giving birth while others were made to have natural births despite the fact that they should have been offered a caesarean. This must have been cruel. The report says that over 200 babies and nine mothers might have survived if they had received the right care.

In addition to what we have read about the actual circumstances, the report also has huge implications for the future of maternity care. The report, of course, makes for harrowing reading—cries for help going unheard; parents having to try to resuscitate their own children because there was no one there to help; and women and babies dying needlessly because the mothers were not listened to. That women were silenced and ignored at their most vulnerable, when they were relying on the NHS to keep them and their babies safe, is shameful. In addition to the NHS, the CQC also failed in its duties as it missed opportunities to stop the poor maternity care.

No woman should ever have to face going into hospital to give birth not knowing whether she and her baby will come out alive. However, these were not just one-offs or isolated incidents of negligence. There was an institutional failing in a system riddled with a toxic culture of bullying, ignoring mothers and deliberating keeping caesarean rates low, even though that was not the right thing for the mother. The entire culture failed to take up the many opportunities to realise that there was a serious problem and to act. We are where we are today because of the persistence and resilience of the families who have suffered, and continue to suffer, and because of their refusal to give up the fight to expose these failings.

The only comfort we can offer them is that their voices have been heard, and that we commit today, in your Lordships’ House, to ensure that these failings are never repeated. For too long, patient safety issues and the voices of women have been an afterthought, leading to the kind of crisis we saw in this NHS trust—and this must change. There can be no compromise on patient safety, which has to be a priority for both health professionals and Ministers.

With this in mind, I will put some points to the Minister. I certainly welcome the acceptance of all 84 recommendations, but how will the Minister monitor the progress that is being demanded through these recommendations, and when and how will this be reported to Parliament?

The report makes it clear that safe services cannot be run unless there is a culture of transparency and accountability. Can the Minister therefore explain how he intends to ensure an open culture within the NHS, with a willingness to learn, particularly within maternity services, and for future failures to be identified and corrected quickly?

Underpinning issues in maternity care, as is the case across so much of our NHS, is the workforce, which is why we have been pushing so hard on this matter in the Health and Care Bill. The NHS is now losing midwives faster than it can recruit them. A recent CQC survey shows that almost a quarter of women were unable to get help when they needed it during labour. Hundreds of pregnant women were turned away from maternity wards last year because there were not the staff available to care for them. What is being done to ensure that the NHS can recruit the midwives that it needs? What is being done to keep the midwives we have in post?

It is only with the necessary workforce that the NHS will be able to ensure that women receive the care that meets their needs and prioritises their safety. That security and respect is all that the families who suffered so much at Shrewsbury want, and it is all that the women who put their and their babies’ lives in the hands of the NHS want. This has to be reasonable, and it has to be done.

[Baroness Walmsley (LD)]

My Lords, I too thank the Minister for repeating the Statement. We must acknowledge that the vast majority of midwives, nurses and clinicians providing maternity services do their very best to provide good care for their patients. It must have been with great sadness that they read—as we read with great sadness—today’s Ockenden report and the previous interim report, which have shone a light on a shocking range of shortcomings in maternity services, leadership and inspections at Shrewsbury and Telford Hospital NHS Trust. I hope that this report will lead, in future, to mothers and babies being as safe as we can possibly make them in our NHS.

The report has been made possible only by the bravery and persistence of all those families who were prepared to go through their trauma all over again when they gave evidence of what happened to them and the awful consequences and pain that followed. From these Benches we offer our thanks and sympathies to all those suffering bereavement and ongoing health issues. The report is also a tribute to the fine work of Donna Ockenden and her team, who used both their professional knowledge and their human qualities to conduct the review with dedication, empathy and attention to detail.

I also commend those members of staff who were prepared to give very candid evidence to the investigators. Such people are sometimes referred to as whistleblowers; I call them courageous, public-spirited professionals. However, their actions were not without risk to themselves and their future, as with many whistleblowers in the health and care services. I therefore ask the Minister: will the special health authority, which is being set up to continue the maternity investigation programme currently run by the Healthcare Safety Investigation Branch, have the same safe-space confidentiality for those giving evidence in the future as the HSSIB, which is currently being legislated for in the Health and Care Bill? The Minister will know how strongly both Houses of Parliament feel about the importance of giving staff absolute confidence that the material they disclose remains confidential in the interests only of learning and improving patient safety rather than laying blame.

The report stated that:

“There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the Trust and a culture of not listening to the families involved.”


I therefore first acknowledge last week’s funding announcement of £127 million by NHS England for maternity services, although this is still significantly short of the £200 million to £350 million recommended by the Health and Social Care Select Committee in June 2021. However, it is surprising to me, in the light of Donna Ockenden’s clear finding that staff shortages risk lives, that the Government, in the other place, continue to resist the amendment of the noble Baroness, Lady Cumberlege, voted for by your Lordships, on assessing, reporting and planning for safe levels of staffing in the NHS and social care. Proper planning cannot take place without an accurate and independent assessment of current supply and future need. In light of the Ockenden report, will the Government change their position on this?

There are currently 2,000 midwife vacancies in the NHS, according to NHS England figures published last month, and the number of midwives in post has fallen since last year. This is going in the wrong direction.

In the debate on the interim report in your Lordships’ House on 14 December 2020, the noble Lord, Lord Bethell, denied that the issues in Shrewsbury and Telford maternity services were linked to understaffing. Does the noble Lord, Lord Kamall, now accept that staffing is an issue? Can he say what will be done about it? As Ms Ockenden rightly says, we need to create a situation where midwives, nurses and clinicians want to remain in the NHS. We will not do that if they are constantly having to battle against staff shortages.

The report also highlights the need for women to be listened to when engaging with maternity services, rather than experiencing a culture of services based around targets for a particular kind of birth. I need hardly say that giving birth is a very personal matter and women’s preferences must be listened to and provided where clinically appropriate. Ockenden emphasised that listening to women and empowering them in their care will lead to improved outcomes. I therefore remind the Minister of the parallel between this situation and telemedicine abortion treatment, where the Government are failing to listen to women’s clinically safe preferences. I was pleased to hear recently that Members of the House of Commons have been listening to women, rather than to the Government.

The report pointed out that what happened in Shrewsbury and Telford was not an isolated incident. In July 2021, 41% of maternity services in England were rated as inadequate or requiring improvement. That is why the report made 15 recommendations aimed at all maternity services across the country, and I understand that the Government have accepted them all. Can the Minister therefore say how implementation of these country-wide recommendations will be monitored and reported on? Will that duty be given to the CQC or will there be a special system?

I finally turn to training. In the debate on the interim report in December 2020, my noble friend Lord Scriven pointed out that:

“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?”—[Official Report, 14/12/20; col. 1522.]


I echo his question today. Will the money for training be ring-fenced and will midwives going for training always be covered by similarly experienced staff?

Despite earlier events, similar although smaller in scale to what happened at Shrewsbury and Telford, there has not been systematic integrated change. Can the Minister therefore assure us that this will happen now, especially under the new regime of integrated care systems? Who will be responsible at the level of NHS England, ICSs and individual trusts, as well as politically, for ensuring that, this time, the changes highlighted by Donna Ockenden are implemented in a timely way, so that no more families will be avoidably deprived of their precious child, mother or wife?

[Lord Kamall (Con)]

I begin by thanking both noble Baronesses for their questions and resisting the temptation to bring too much politics into it. This is an issue that we all feel very strongly about. I will try to answer as many questions as I can; I apologise in advance if I do not answer all the questions today. I have quite a big briefing pack, which I have been through a number of times. I commit to writing to noble Lords and the noble Baronesses to fill the gaps.

As the noble Baronesses said, we accept all the actions outlined in the report. The Secretary of State has asked NHS England and NHS Improvement to write to all the trusts across England about the final Ockenden report, and will ask all maternity services across England to assess their services against the 15 immediate and essential actions outlined in the report —and take action where they fall short. As the noble Baronesses acknowledged, NHS England and NHS Improvement have announced that they will invest £127 million in maternity care; that money will go towards the NHS maternity workforce and improving neonatal care.

We have also seen work under way to tackle some of the key issues in the report, such as the £5 million for the Avoiding Brain Injury in Childbirth collaboration project, the establishment of a special health authority to continue the work, which I shall go into later, and the development of 17 new maternal medicine networks. We will update the House as appropriate on the monitoring.

We have to look at the culture; I completely understand the points made. Strong leadership will now be established across the system, with the appointment of named regional and local maternity safety champions led by two national maternity safety champions, Matthew Jolly and Jacqueline Dunkley-Bent. In every trust, front-line maternity safety champions—one obstetrician, one midwife and one neonatologist—will work closely with a board maternity safety champion to promote unfettered floor-to-board communication. We have also tried to make progress in shifting away from a defensive blame culture in healthcare towards a culture in which we recognise and accept when things go wrong and look to learn.

I thank noble Lords for their engagement, particularly over the HSSIB, during the passage of the Bill. I think we all agreed that it was important that we kept as many people as possible out of the “safe space” to encourage people to come forward. However, as we have seen in these cases, people were bullied and disincentivised from coming forward; some even withdrew their names.

Last year, there was a £500,000 fund to provide maternity leadership training for NHS maternity and neonatal leaders. We looked at addressing the issues raised in the first Ockenden report—to use that phrase again, “between ward and board”—to make sure that there was proper accountability and training.

On workforce, as I said, NHS England and NHS Improvement have the investment. In addition, there is £95 million in new funding to support the recruitment of 1,200 more midwives and 100 more obstetricians, and to support multidisciplinary team training. The department has also commissioned the Royal College of Obstetricians and Gynaecologists to develop a new workforce planning tool to improve how maternity units calculate their medical staffing requirements. The tool will calculate the number of obstetricians at all grades required locally and nationally to provide a safe, personalised maternity service within the context of the wider workforce. Health Education England has also been working with stakeholders towards a targeted increase of 3,650 midwifery student training places by the end of 2022-23.

One concern that was raised when I spoke to officials and asked for briefings before this evening was whether reports such as this one would disincentivise people from coming forward to work in midwifery. We have to be very careful that we are as open as possible and that we make sure that the system learns where there are problems. People are human, and they will be concerned about coming forward. So we have to get the right balance and have safety, training and awareness all the way through, making sure that it is patient-centred.

I shall try to answer as many questions as I can; I know that other noble Lords want to come in. In terms of deterring midwives from leaving—I know that there is a real concern here—the NHS people plan focused on improvement and retention. There is a well-being guardian role focused on: healthy work environments and safe spaces; empowering line managers to hold meaningful conversations; emotional and psychological support; a dedicated health and care staff support service; a bereavement helpline; free access to a range of mental health apps; a range of counselling and talking therapies; and online resources. Money has also been invested in 14 mental health hubs across the country, and £6 million has been set aside for a national support service for critical care staff.

We have to tackle bullying and harassment in the service. The people plan deals with a number of issues on that; there is also a visibility and respect framework and a toolkit. A number of projects and pilots are under way across the NHS to support organisations to see what works and where we can learn from that.

There were some questions about the special health authority, which we see as a key part of work to improve the investigation and learning culture. The investigators will carry out timely and independent individualised investigations into maternal and neonatal deaths and incidents across England. The SHA’s investigation will be family-centred and mother-centred, but it will also provide families with answers to questions about why an incident occurred or why their baby died, rather than just sweeping this away. The learning from these investigations will be shared at a local level and across the wider system. As an independent body, the special health authority will continue the work of the HSIB from 2023, and maternity investigations will continue during this time, without interruption, until the SHA is fully operational—this is specifically for maternity.

As for what the Government are doing to make sure that women’s voices are heard, we have the women’s health strategy—I know that noble Lords have heard that before—and we are looking at multidisciplinary training in the maternity workforce. There is a debate within the training community about whether you train someone to be a midwife first or whether they should start as a nurse and have nursing skills first. I will stop there to allow other noble Lords to ask questions.