Baby Loss Awareness Week

Cherilyn Mackrory Excerpts

Thursday 19th October 2023 Commons Chamber

[Tim Loughton (East Worthing and Shoreham) (Con)]

It is a pleasure to speak on this important subject. I pay tribute to the hon. Members for Sheffield, Hallam (Olivia Blake) and for North Shropshire (Helen Morgan), and the others who have secured the debate. It has become something of a tradition that we mark Baby Loss Awareness Week, although we were not able to do so last week because of the recess.

This has also become one of the more emotional and harrowing debates—I have sat through many debates over many years—which is a great tribute to how this place has progressed. When I first came to this House all those years ago, as you did, Madam Deputy Speaker, baby loss was a subject that was not discussed. Certainly, the personal experiences of Members, particularly female Members, going through the trauma we heard about in the earlier debate and through baby loss generally, let alone the experience of partners, did not come out into the open. The stigma surrounding mental health meant that no Member of Parliament would dare to raise in public the fact that they might have some mental illness problems. Why would they not? A lot of the population have such problems, and we are just humans like the rest of the population, doing a particularly stressful job.

The progress that we have made over the 26 and a half years that we have been in Parliament, Madam Deputy Speaker, is a real tribute to this place, and to the bravery and openness of hon. Members who have come forward with their personal experiences. Those experiences enrich the way in which we scrutinise Government Departments, rules, regulations and legislation that needs to be brought in to deal with related problems. I pay tribute to all those who have shared their experiences. I was listening to the previous debate in my room, in between meetings, and I particularly pay tribute to my hon. Friend the Member for Stafford (Theo Clarke), as she said it was the first time that the specific issue of birth trauma had been mentioned here. She opened up incredibly emotionally about her own experiences.

I am glad that in my hon. Friend’s winding-up speech she mentioned how the issue affects dads as well. It is not a female-only issue; it is a parents issue. Where there are two parents involved in a child’s life, the impact of baby loss can be incredible on the male parent, and we should never forget that. Too often, health officials speak over the heads of fathers to the mothers, but fathers have an equally vested interest in what happens, not only to their partner but to their new-born baby as well.

[Cherilyn Mackrory]

Does my hon. Friend agree that the fact that aftercare for fathers is often lacking places a huge burden on relationships? Sadly, the statistics show that 50% of relationships can break down after the loss of a baby. Does he agree that we need to do much more to support fathers, as well as mothers, after the loss of a baby?

[Tim Loughton]

My hon. Friend, who again has great experience and has been exceedingly forward with her own experiences, is absolutely right. There have been many studies on maternal perinatal mental health problems. The latest estimate is that that costs this country over £8 billion, and there has been an increase in perinatal mental health problems among women, exacerbated by the lockdown.

As happened to our own colleagues, for many months babies born during lockdown did not come into contact with another baby, or with extended family members such as grandparents, who would usually be at the hospital bedside to welcome a new baby, but were not allowed to be there. Speaking as the chairman of the all-party parliamentary group for conception to age two: first 1001 days, we are only starting to see the considerable impact of that on babies. We will only start to see that as those babies grow up and go to school.

However, there have not been as many studies about the impact on the mental health of fathers. There is good evidence to suggest that fathers can suffer considerably, yet the support networks, which are still not good enough for mums, are not nearly good enough for fathers. It is a false economy not to support that.

In a minute, I want to have another rant about my Act, the Civil Partnerships, Marriages and Deaths (Registration etc) Act 2019—that is the real reason for my coming to this debate, although I always try to take part, because the Act deals with stillbirth, in particular—but first I will make some general comments.

It is good that we are discussing this issue and that the profile is so much higher than it has been in previous years, but there is a lot of work still to do. The stillbirth rates have come down and there has been progress. Back in 1993, there were 5.7 stillbirths per 1,000 births. There were 2,866 stillbirths in 2021, so the figure is now about 3.8 or 3.9 stillbirths per 1,000 births. There has been progress, but in order to get to the target under the national maternity safety ambitions, which was launched in 2015, we need to get that figure down to about 2.6 by 2025, so there is a lot of work still to do on stillbirths.

Compared with other European countries, our record on stillbirth remains poor. We rate sixth worst out the 28 European Union countries plus the UK. The countries below us are Bulgaria, Malta, Croatia, Slovakia and Romania, which have perhaps traditionally not had as advanced and sophisticated health services as we have in this country. There is no real excuse why we have not made more progress.

--- Later in debate ---

[Tim Loughton]

I am grateful to my hon. Friend for putting on record what his local hospital is doing, and I hope that that is happening around the country. Certainly, my own hospital takes great pride in its bereavement suites and they have made a big difference to the impact on parents in its maternity wing.

We have had the Ockenden report as well as the Cumberlege review, so there has been a lot of activity from the Department of Health and Social Care, but we need to go so much further. Although I will not go into detail here, I wish to reference the high incidence of stillbirths and baby loss among the black, Asian and minority ethnic community, who are something like five times less likely to receive maternal aftercare.

As hon. Members have mentioned, there are also real challenges and big vacancies in the midwifery workforce. As has been said, 38% of maternity services have been rated as requiring improvements in safety, so there is still a long way to go. One thing that has particularly alarmed me—I am sure other hon. Members will have had the briefing from that excellent charity, Sands—is the state of perinatal pathology. I think my hon. Friend the Member for Truro and Falmouth (Cherilyn Mackrory) may be talking further on that. Currently, there is a significant proportion of parents who have to wait more than three to six months for their babies’ post mortem to be undertaken and for the results to be communicated to them. Those waiting times are then further exacerbated by poor communications about what is happening. Having gone through the trauma of losing a newborn baby, parents then have to wait a long time to find out what happened, which causes them additional trauma.

As I mentioned earlier, there is the whole issue of mental illness and, in particular, the impact of mental illness and depression and the prevalence among teenage mothers. It is important that we deal with that early and that the support is there because we know—the Minister mentioned this in the previous debate—about the high incidence of suicide linked to the perinatal period.

Therefore, this is an important subject. Good work has been done. The Government have good plans, but there is still a lot of work to do before we can genuinely say that this is a very safe country in which to give birth and we rank with the top countries across the rest of Europe.

I wish to talk about my excellent private Member’s Act, which passed through Parliament some time ago. Madam Deputy Speaker, you will not be surprised to hear me mention it again because I have raised it on the Floor of the House many times. I have harangued the Minister about it many times and will continue to do so.

My Civil Partnerships, Marriages and Deaths (Registration etc.) Act 2019 passed through its final stages in this House on 15 March 2019. It received Royal Assent on 26 March 2019; that is 1,303 days ago. It did four things. First, it enabled opposite sex couples to have a civil partnership. That became law on new year’s eve 2019. On that day, 167 couples availed themselves of that opportunity and many thousands have since, so we can tick that box. A second part of the Act enabled for the first time the names of mothers to be included on marriage certificates. Up until then, they did not exist, which particularly added insult to injury if it was the mother who brought up the child who was getting married and the father, whose name does appear, had never been on the scene at all. That at last was reversed with my Act—another tick.

Another part of the Act mandated the Secretary of State for Health and Social Care to produce a pregnancy loss review. A committee was set up—I sat on that committee —and in July this year the independent pregnancy loss review, which contained many recommendations—there were some good things in it, even though it had not met since 2018—was at last published, so another tick.

The fourth part of my Act was on coroners’ investigations into stillbirths. What was agreed by this House unanimously, with Government support, following much scrutiny in the other place as well, was that the Secretary of State must

“make arrangements for the preparation of a report on whether, and if so how, the law ought to be changed to enable or require coroners to investigate still-births”,

and that, after the report had been published, the Lord Chancellor may, by regulations, amend part 1 of the Coroners and Justice Act 2009. It was a very simple amendment to ensure that, in future, coroners had the power to investigate stillbirths. It did not require any more primary legislation. It required a one-line amendment to the Coroners and Justice Act.

When I made my speech for my private Member’s Bill on 15 March 2019, I could not have been more wrong. I said then that I knew that we were pushing at an open door with my last measure, as the Health Secretary had signalled his support for it at the Dispatch Box during a statement on stillbirths in November. I then set out the anomaly in the law where coroners in England have the power to investigate any unexplained death of any humans unless they are stillbirths. That is because a baby who dies during delivery is not legally considered to have lived. If the baby has not lived, it has not died and coroners can investigate deaths only where there is a body of a deceased person.

Most people agreed—certainly the coroners themselves, who strongly supported this—that that is an anomaly in the law. Given some of the scandals that I will come to in a minute, it has given rise to a suspicion—this is the point that the hon. Member for North Ayrshire and Arran (Patricia Gibson) raised—that some stillbirths that went unexplained might have been avoidable, and were mistakenly registered as stillbirths because that effectively excluded the coroner from launching a further investigation. My Bill was therefore simple in its aim.

A consultation was launched, actually before my Bill became an Act, because the Secretary of State was so supportive of it and saw it as a formality. The consultation on the changes closed on 18 June 2019—over four years ago—and has still not been published. In order for new regulations to come in, the consultation and subsequent proposals have to be published, but we still have not got over the first bar of publishing the consultation. I have frequently queried when the Government will publish the consultation, and have frequently received a barrage of excuses. Of course, covid was the first excuse for why the consultation results—not even the proposals—could not be published.

The matter was chased up by the Justice Committee, which produced its own report on coroners and reinforced the need to get on with the measures in my Act. That message was reinforced by the Health and Social Care Committee, which also produced a report to say that the Government needed to get on with the measures. Today’s Minister, for whom I have a lot of time, as my near neighbour in Lewes, has written to me several times. One of the excuses was that we needed to wait for the Health and Care Act 2022 to go through in the last Session because of various considerations that could have an impact. That Act passed last year, so is not a consideration anymore.

We then had to get the pregnancy loss review published, for which we had waited since 2019. That has now been published, as I have said. We then had the further excuse that the Ministry of Justice was dragging its feet. The problem is that it is a Department of Health and a Ministry of Justice issue. I have tackled the Minister for Justice on several occasions. I asked for a joint meeting with the Minister for Health and the Minister for Justice. That meeting was cancelled six times, until it eventually happened on 21 March this year, when I was told that everything was in hand and being sorted out. I raised the matter again in Justice questions on 12 September. I was told:

“Both the Health Minister and I are pushing this as fast as we possibly can.”—[Official Report, 12 September 2023; Vol. 737, c. 766.]

This is appalling. Madam Deputy Speaker, you and I have been in this House for an equally long time. I cannot remember a piece of legislation waiting to be enacted for as long as this, particularly when there appear to be no objections to it. It has been passed unanimously and is not contentious; the coroners want to do it. It is absolutely extraordinary. I will take this opportunity to put it out in the open yet again that the Government need to get on with this. The legislation is even more important now than when it was passed in 2019, and when I produced it as a private Member’s Bill in 2017.

Four things needed to be resolved about how coroners would look at these matters, and they have all been resolved. First, we all agreed that they should look only at full-term stillbirths. That is where a stillbirth is least likely to happen, and therefore more questions arise. I think that everybody agreed on that. Secondly, it should be at the discretion of the coroner. The coroner will certainly not want to look at every single stillbirth, but where questions are raised by the parent or others that something has gone a bit awry and we need more information, the coroner can decide at his or her discretion whether there is a case for further investigation. We are talking about dozens, or scores, of cases, not hundreds or thousands.

Thirdly, it will be up to the coroner to decide, even if the parents do not want a review. That was a difficult one, but there is evidence that some stillbirths can be brought on by domestic violence during pregnancy, and obviously there may be a cover-up because a mum is being coerced. It is right that there should not be a veto and it should be down to the coroner to decide. Fourthly, the coroners have decided that it is not a significant resource issue. We do not need to train up a fleet of specialist coroners; they always want more money, but they think that they can simply take on the responsibility. All those things have been resolved. There are no outstanding questions, but as I said the need for the legislation has grown since it went through.

I do not need to remind everybody about the various scandals that have happened. The Nottingham maternity review currently under way covers the latest of those revelations. It will be the UK’s largest maternity review, with 1,266 families having already contacted the review team with their concerns. The Shrewsbury and Telford Hospital NHS Trust review, which has already been mentioned, of the deaths of more than 200 babies and nine mothers between 2000 and 2019, found that 201 babies could or would have survived had the trust provided better care, and that families were wrongly blamed when their babies died, were locked out of inquiries into what happened, and were treated without compassion and kindness.

The Morecambe Bay review in 2015 found unnecessary deaths of 11 babies and one mother between 2004 and 2013 due to oxygen shortages, mismanaged labour, failure to recognise complications, and so on. When the East Kent review was published, the headline was that the East Kent Hospitals University NHS Foundation Trust was logging baby deaths as stillbirths when in fact they were not stillbirths. What would the reason for that be? Potentially a cover-up, so that a further investigation by a coroner could not take place.

The East Kent review into the ongoing problems with the trust was described as harrowing, with more than 80 concerns about midwives and nurses working at the trust investigated by the regulators since 2015, including cases involving the police. Eleven midwives and nurses from the trust have been struck off, suspended or placed under conditions in relation to such cases, and 64 doctors from the hospital have been subject to investigation by the General Medical Council over the last decade, with three struck off and three suspended. The report showed a failure to implement the recommendations of earlier reports, allowing failings to continue at East Kent, and at other hospitals elsewhere in the country.

It needs reinforcing that most nurses, midwives and doctors do a fantastic job in difficult circumstances. They most of all will want to ensure that incompetence by a few, and potential cover-up, do not effectively undermine the reputation of those working in maternity care across the whole country.

[Cherilyn Mackrory]

My hon. Friend is making brilliant points, which I am so grateful for. Does he agree that those healthcare professionals will probably welcome this because it will start to break down the blame culture that the hon. Member for North Ayrshire and Arran (Patricia Gibson) talked about?

[Tim Loughton]

My hon. Friend is absolutely right. We do not want a blame game. When I was the Minister for Children and we reviewed extraordinary and harrowing child deaths at the hands of various people, it was the blame game for social workers that so undermined the profession. It is not social workers who kill children; it is carers and others with evil intent. But where there has been incompetence, where the system has perhaps contributed to that incompetence or has effectively obstructed a professional from getting on with their job in the way that they would like to and can do, that is where we need the findings. In some cases, that may require a coronial investigation, which can look under every stone and really get down to the roots of the problems, rather than just point a finger of blame with which the whole profession gets tarred.

That is why—you will be relieved to hear, Madam Deputy Speaker, that I am about to end—my Bill, if I do say so myself, brought in some important and necessary changes in the law, most of which have happened, have been welcomed and have gone very well. This change was widely welcomed, but has not been enacted, and the need for it to be enacted has never been greater.

Back in 2019, ahead of the December election, I had promised couples that the regulations to allow civil partnerships would be brought in before the end of the year. On the last day before Parliament was dissolved, those regulations were brought to the Floor of the House, and I had to move them—that would normally be done in Committee—in order to get them through in time with the help of the Chief whip. I do not want to have to do the same at the very last breath just ahead of the 2024 election, because there is no excuse for this not having happened several years ago.

I plead with the Minister. She supports these changes. The Government support these changes. This Parliament—both Houses—supports these changes. Parents, professionals and coroners support these changes. Why is she not getting on with bringing them in? Please, please, please knock heads together across both Departments and get these regulations laid, get the consultation results published, and let us bring in an additional layer of safety for parents who go through the trauma of stillbirth and have unanswered questions when they leave hospital without the child that they had hoped they would leave with.

[Cherilyn Mackrory (Truro and Falmouth) (Con)]

It is a great honour to follow my hon. Friend the Member for East Worthing and Shoreham (Tim Loughton), who set out very clearly his work in this space, for which I am very grateful. I extend an offer to him to use the all-party parliamentary group on baby loss for anything that we can do to help bring about the conclusion that he requires, because I believe he is absolutely right.

I am incredibly grateful to my APPG co-chair, the hon. Member for North Shropshire (Helen Morgan), for requesting this debate and to the Backbench Business Committee for allowing it today. As my hon. Friend the Member for East Worthing and Shoreham has already said, it is now a tradition in this place to set aside time to discuss Baby Loss Awareness Week. I have had the privilege of chairing the APPG on baby loss for the last three years, and I also chair the all-party parliamentary group on women's health, which means that much of my time in this place is taken up with supporting women and families through some truly uncomfortable and sometimes deeply unpleasant experiences.

As colleagues may already be aware, Baby Loss Awareness Week was last week, when the House was in recess, but this debate is now marked in the calendar of this place. I know that many right hon. and hon. Friends are in other places today for many good reasons, but there is normally a lot of collaboration across the Benches. We forget party politics and talk about what is important. This debate should be a tradition in this place because it shows Parliament at its best. Not only does it allow the general public to remember that we are all human, but it also means that tribal party politics is put aside, allowing us to try to work together on these important issues.

I want to place on the record my sincere thanks to the APPG for the work that it did before my time in this place under the guidance of my right hon. and learned Friend the Member for Banbury (Victoria Prentis), now the Attorney General, and my hon. Friend the Member for Colchester (Will Quince). Both of them gave powerful testimonies in this place before I arrived. I also thank my former co-chair on the APPG, now Chancellor of the Exchequer, my right hon. Friend the Member for South West Surrey (Jeremy Hunt), who has such a passion for this topic from his time as Health Secretary. It is through his actions that we are now seeing the NHS workforce plan come to fruition. It was a deeply held passion of his, and it is the key to unlocking a lot of what we talk about in this space.

The APPG, again before my time, established the national bereavement care pathway to improve bereavement care and reduce variabilities throughout the country. It has been adopted by the majority of trusts, but it is a constant challenge to ensure that it is maintained given all the competing priorities facing the NHS. I ask the local health leaders watching the debate today to please understand how important the pathway is. We have had two debates in the Chamber this afternoon on topics that affect so many women and so many families. I ask local health leaders not to put the pathway to one side because it could be a cost-saving exercise in their trust.

I also thank colleagues on both sides of the House who have in the past taken the time to remember the babies that have sadly been lost. I am approached day after day by people who work in this place—some of whom Members would never guess—who have told me privately that this happened to them decades ago and that they still cannot bring themselves to talk about it. We are left to be the advocates for everybody, and if we dug deep, everybody would know somebody who has suffered the loss of a baby or one very close to them.

I am really grateful for the local support in my community. I want to give a big thank you to Mike Spicer and the team at A&P in the port of Falmouth for lighting up their crane in pink and blue last week for Baby Loss Awareness Week. I also thank Nick Simmonds-Screech and the team at Costain who lit up one of the bridges over the A30 in pink and blue during the dualling works. It means a huge amount, and they did it as a favour to me, but all the Cornish families who have lost a baby will have seen those two monuments lit up. It just shows that we are thinking about them.

As I said, Baby Loss Awareness Week was last week, and at the local service in Truro I met the team from the Royal Cornwall Hospitals NHS Trust, including the bereavement midwives. Karen Stoyles, our chief nurse, was sadly absent with covid. I put on record my thanks to Kim O’Keeffe for all her work. We also met parents and families, and marked the occasion with the traditional wave of light, when people across the country who have lost a baby, or people who want to remember those who have lost a baby, light a candle at 7 pm and share the photographs. It means a lot, and that is why I wanted to get all that on the record so that we do not lose momentum in this space.

In my constituency of Truro and Falmouth, we are building a brand-new women and children's hospital. The principle behind the hospital is to deliver a holistic service to families in Cornwall, whether through sexual health or reproductive health advice or care throughout their pregnancy or the aftercare that mothers desperately need. When the hospital is finished in the next couple of years, my constituents will have on their doorstep a facility that specialises in a range of women’s health concerns. I hope it will be a sanctuary for women’s health and a place that really delivers a social benefit, leading to a tangible reduction in baby loss risk throughout the south-west. It will include projects such as e-records, digital wards and, hopefully, electronic bed management. That all sounds very technical, but it frees up clinical staff to be clinical and to be at the bedside caring for patients.

My experience of chairing the two APPGs has confirmed to me that the Government do take baby loss incredibly seriously. We also owe thanks to charities such as Tommy’s, Sands and the Lullaby Trust for all their work in this field. They have incredible teams that do some of the best work, and I will always be grateful for everything they do to help me in this journey. It is also appropriate for me to thank the Minister for her efforts in keeping this at the top of the Department’s priority list, and I appreciate her for addressing the Sands and Tommy’s joint report launch in Portcullis House earlier this year.

It is very easy for our deliberations in this place to concentrate on, and constantly revert to, complaints about staffing levels. Although staffing is vital, it is prudent for us to focus on the core issues of quality practice and the information provided to parents throughout pregnancy. That is why I always go on about the continuity of care. We mentioned in the previous debate how that can help with baby loss in so many ways, and it has been proven to work in hospital trusts in areas where there is a greater chance of social deprivation. As soon as we can get staffing levels up to a safe standard, that continuity of care should be rolled out across the country. It picks up not only on lifestyle issues that could harm a baby, but on things such as domestic violence, which my hon. Friend the Member for East Worthing and Shoreham mentioned a moment ago, and so many other issues that can contribute to the preventable loss of a baby, particularly at full term. I cannot stress enough how important that is, and I will keep going on about it until we start to make progress.

I will quickly touch on support for parents after the event and the additional mental health support that we could provide. Mums and dads experiencing the loss of their baby will go through the worst time of their life, and everybody will have their own way of processing the grief. Some people will never get closure on it. As my APPG co-chair the hon. Member for North Shropshire mentioned, at our last meeting we listened to experts in the field of postnatal pathology and highlighted the recruitment and waiting-list issues that have been holding some families back from the closure that they deserve.

In an inquiry that we held a couple of years ago, it struck me that a baby born in Northern Ireland has to be taken to Alder Hey Hospital in Liverpool for a post-mortem—I think that is still the case—and it can take months and months before parents get their baby back. Some couples wait nearly a year. I think the same may apply to the Isle of Wight, but do not quote me on that. Certainly, different parts of the country have different set-ups. In Cornwall, our babies go as far as Bristol, and at the moment, the wait time for a post-mortem is weeks rather than months, but, given the stories I hear from around the country, it is a postcode lottery that we need to address urgently.

[Helen Morgan]

I want to re-emphasise that point because it is so important. When a baby goes for a post-mortem examination, it is in transit and away from its parents. The parents are often unable to keep track of the remains of their baby and when they will get them back. Does the hon. Lady agree that we need to beef up that whole process to give parents the support that they need at such a difficult time?

[Cherilyn Mackrory]

I agree wholeheartedly. There are a couple of ways in which we can do that. One is the roll-out and expansion to all centres of minimally invasive autopsies and other non-invasive techniques. Not all post-mortems need to be invasive. Certainly, there needs to be an expansion of placental autopsies—if that is the right phrase—because the cause can often be found that way without the need to keep the baby for an awfully long time. We can do a lot more work in that space. The pathologists we have spoken to all want that work to be done, and if they had more time, they would be able to do more research on why it happens. At the moment, a baby could be lost at 38 or 40 weeks for absolutely no reason at all, and the parents will never find out why. Blame can be thrown around for the different things that happened on the day of the birth, but we just do not know the reason, and that is not acceptable in 2023. We will never find out every reason for every lost baby, but we could do an awful lot better.

I am told by Sands, the baby loss charity, that the shortage of perinatal pathologists has been growing over decades, and in recent years, mutual aid between pathology centres has reduced the impact on the national delivery of services, but that approach is breaking down as the capacity of overburdened centres to pick up cases beyond their own areas is dwindling. I cannot see that getting better without direct help in the near future.

We also need to get the basics right. The Royal Cornwall Hospital in Truro has the Daisy suite, which is a separate bereavement suite of rooms for those who lose their babies. It has its own bathroom and kitchen—not to put too fine a point on it, but being in labour puts extra pressure on your bowels and bladder, and you can be sick a lot. Being in that space is better not only to face the trauma, but because you do not have to see other parents holding their live babies. That was not available when I was going through the process of losing our baby. There was a girl there by herself—a young mum—who was 38 weeks pregnant when her baby had just stopped moving. Suddenly, I felt very well supported because I had someone there with me. Although we had a room to ourselves, I had to troop and up down the corridor to the bathroom, and I saw healthy babies, pregnant women who were glowing, and families who were just looking forward to taking their babies home. That is just too much to process, so I would be very grateful if we could avoid that. I was surprised to hear this week that the Snowdrop unit at Derriford Hospital has only just opened, but I am so pleased that parents in Plymouth can now make use of it at a time when they will be at their lowest.

This week, a colleague mentioned a constituent of hers who had delivered a stillborn baby and was left on a normal maternity ward—that is unacceptable. The woman was cradling her stillborn baby and people would walk past and congratulate her on the birth because they had no idea that her baby was not alive. She did not know what to say, so she just sort of nodded. Why, oh why, was that poor woman left in that vulnerable state? Most bereavement suites are funded with charitable donations, perhaps with some departmental funding. We need to get the basics right and in place. Although we cannot get everything right quickly, we can easily make things better.

The Royal College of Midwives “State of Maternity Services 2023” report sets out stark staffing shortages in some parts of the country. It acknowledges, however, that the number of people enrolling on maternity courses is up since 2019. Like me, the RCM supports the degree apprenticeship route, and it was fun to see its chief executive talk to a room of midwives who were quite cynical about degree apprenticeships. She was waxing lyrical about how much apprentices loved them, about how much experience they were getting on the ward, and about how they come out of it debt-free and with bags of experience.

What I found interesting is that that is a great way to keep experienced midwives on the ward. At the moment, a lot of them are suffering burnout, which is why staffing levels are leaking most starkly. A midwife in her 50s might have had enough, but if we offer them the chance to come back on the ward for three or four shifts a week to help train up new midwives, through live births and with practical help, they can do that at their own pace, and we would not lose all that experience all at once, so I am a huge advocate of the degree apprenticeship route.

Cornwall has started doing that. As I mentioned in the previous debate, Kim O’Keefe, chief nursing officer at the Royal Cornwall Hospitals NHS Trust, told me in the summer that we now have no midwifery vacancies in Cornwall. Not only has every single vacancy been filled but—this is unusual in this country—in Cornwall we have a waiting list of people who want to become midwives. That is testament to the work that the team there has been doing. Notwithstanding the fact that they are currently doing it in a decaying building while they wait with bated breath for our new women and children’s hospital, that all plays into better outcomes for parents and babies in Cornwall in the years to come.

There is so much to do in this space and so much more that I could say. We have not even spoken at length about dads, but a passion of mine is ensuring that dads are looked after during and after the loss of a baby. I do not want to get too personal about it without my husband’s consent, but it was very difficult for him to meet his baby. That is a personal choice. He was never offered any counselling at all. Being a fisherman, he just went out to sea. He has dealt with it in his own way. My advice to any couple watching this debate who has recently lost a baby is: please, please, please rely on other people outside your relationship—rely on family members, rely on your friendship circle—because although you will come back together, you cannot always grieve at the same time and at the same pace. A few moments ago I gave my hon. Friend the Member for East Worthing and Shoreham the statistic that 50% of relationships break down. That is because couples want to rely on the person who has always been there for them, but that person is suffering just as much and cannot always be there.

[Mrs Sharon Hodgson (Washington and Sunderland West) (Lab)]

I did not mean to interrupt the hon. Lady. I am so grateful to her for giving way. Before she ends, I just want to commend her on picking up the mantle as one of the chairs of the all-party group on baby loss. I was one of the founding members, along with the right hon. and learned Member for Banbury (Victoria Prentis), the right hon. Member for Chichester (Gillian Keegan) and the former Member for Eddisbury, Antoinette Sandbach. We all got together as parents who had been through baby loss and set up the all-party group. I am not as involved now as I would like to be, but I commend the hon. Member for Truro and Falmouth (Cherilyn Mackrory) for her energy and enthusiasm in keeping it going.

While I am on my feet, I have to commend the hon. Member for East Worthing and Shoreham (Tim Loughton) for his absolute, total commitment and drive for the last six-plus years in trying to get all elements of his private Member’s Bill through the House—those that have been passed by the House but are still not fully through. I disclosed my baby loss in the debate on his private Member’s Bill in 2017. I lost my baby 25 years ago, but the first time I talked about it really outside my immediate family was in 2017—I know the hon. Lady mentioned that point. I commend him, and I honestly hope that when the Minister responds we will get some good news on some of those final measures.

[Cherilyn Mackrory]

I am really grateful to the hon. Lady for sharing that with me. I apologise; I knew there would be so many Members I missed off my list. It is an open thank you to everybody who set up that APPG. I also did not mention the hon. Member for North Ayrshire and Arran (Patricia Gibson), who is here every year for the baby loss awareness debate and constantly reminds us of her loss. Baby Loss Awareness Week is not easy. We do it because we want to help other people, but it always brings it back. It was very raw for me on Sunday at the service in Truro and also for my mum. I pay tribute to everybody who works in this space. As I said in the previous debate to my hon. Friend the Member for Stafford (Theo Clarke), who is new on this journey, you have to look after yourself so that you can look after other people.

I will conclude. There is so much we can do here. I am glad the Minister is listening—she always is—and I look forward to working with her and anybody else who wants to, because we have to get it right for everybody, everywhere.

--- Later in debate ---

[Patricia Gibson]

I thank my hon. Friend for his intervention. I can see that the Minister was listening carefully, and I am sure she will want to take that back to her colleagues in Cabinet who can take the action that would allow parents who want a certificate before 24 weeks to have one. I also share his view about the importance of the charitable work that is done to support not only mums and dads but grannies and grandfathers when a stillbirth happens, providing them with the local, sensitive support that they need, because it is not always forthcoming from the NHS. When people try to regroup after this kind of loss, that ongoing support in the community is really important.

We are seeing too many maternity failings, and now deep concerns are being raised about Nottingham University Hospitals NHS Trust. I understand that the trust faces a criminal investigation into its maternity failings, so I will not say any more about it. The problem is that when failures happen—and this, for me, is the nub of the matter—as they did in my case at the Southern General in Glasgow, now renamed the Queen Elizabeth University Hospital, lessons continue to be not just unlearned but actively shunned. I feel confident that I am speaking on behalf of so many parents who have gone through similar things when I say that there is active hostility towards questions raised about why the baby died. In my case, I was dismissed, then upon discharge attempts were made to ignore me. Then I was blamed; it was my fault, apparently, because I had missed the viewing of a video about a baby being born—so, obviously, it was my fault that my baby died.

It was then suggested that I had gone mad and what I said could not be relied upon because my memory was not clear. To be absolutely clear, I had not gone mad. I could not afford that luxury, because I was forced to recover and find out what happened to my son. I have witnessed so many other parents being put in that position. It is true that the mother is not always conscious after a stillbirth. Certainly in my case, there was a whole range of medical staff at all levels gathered around me, scratching their heads while my liver ruptured and I almost died alongside my baby. Indeed, my husband was told to say his goodbyes to me, because I was not expected to live. This level of denial, this evasion, this complete inability to admit and recognise that serious mistakes had been made that directly led to the death of my son and almost cost my own life—I know that is the case, because I had to commission two independent reports when nobody in the NHS would help me—is not unusual. That is the problem. That kind of evasion and tactics are straight out of the NHS playbook wherever it happens in the UK, and it is truly awful.

I understand that health boards and health trusts want to cover their backs when things go wrong, but if that is the primary focus—sadly, it appears to be—where is the learning? Perhaps that is why the stillbirth of so many babies could be prevented. If mistakes cannot be admitted when they are made, how can anyone learn from them? I have heard people say in this Chamber today that we do not want to play a blame game. Nobody wants to play a blame game, but everybody is entitled to accountability, and that is what is lacking. We should not need independent reviews. Health boards should be able to look at their practices and procedures, and themselves admit what went wrong. It should not require a third party. Mothers deserve better, fathers deserve better, and our babies certainly deserve better.

Every time I hear of a maternity provision scandal that has led to stillbirths—sadly, I hear it too often—my heart breaks all over again. I know exactly what those parents are facing, continue to face, and must live with for the rest of their lives—a baby stillborn, a much-longed-for child lost, whose stillbirth was entirely preventable.

[Cherilyn Mackrory]

I am really grateful to the hon. Lady for the testimony she is giving, and I absolutely agree with almost everything she is saying. However, does she agree that there is a very big difference between a genuine mistake that a midwife or health professional might make and negligence, and does she think we need to get better at differentiating those two things, so that healthcare professionals are not afraid to come forward and give the right information when an investigation takes place?

[Patricia Gibson]

I absolutely agree with the hon. Lady. The frustration, and the piling of trauma on tragedy, comes from the inability to engage at any level when things go wrong. Everybody knows that things can go wrong. People are human and they will make mistakes. It is what happens afterwards that matters. That is what matters to bereaved parents.

Some people talk about workforce pressure, and it has been mentioned today. However, to go back to the point made by the hon. Member for Truro and Falmouth (Cherilyn Mackrory), for me and, I think, many of the parents who have gone through this, the fundamental problem is the wilful refusal to admit when mistakes have happened and to identify what lessons can be learned in order to prevent something similar happening again. To seek to evade responsibility, to make parents feel that the stillbirth of their child is somehow their own fault or, even worse, that everyone should just move on and get on with their lives after the event because these things happen—that is how I was treated, and I know from the testimony I have heard from other parents that that is how parents are often treated—compounds grief that already threatens to overwhelm those affected by such a tragedy. I do not want to hear of another health board or NHS trust that has been found following an independent investigation to have failed parents and babies promising to learn lessons. Those are just words.

When expectant mums present at hospitals, they should be listened to, not made to feel that they are in the way or do not matter. How hospitals engage with parents during pregnancy and after tragedy really matters. I have been banging on about this since I secured my first debate about stillbirth in 2016, and I will not stop banging on about it. I am fearful that things will never truly change in the way that they need to, and that simply piles agony on top of tragedy. I thank Donna Ockenden for her important work, and I know she will continue to be assiduous in these matters in relation to other work that she is currently undertaking, but the health boards and health trusts need to be much more transparent and open with parents when mistakes happen. For all the recommendations of the Ockenden report—there are many, and they are all important—we will continue to see preventable stillbirths unless the culture of cover-ups is ended. When the tragedy of stillbirth strikes, parents need to know why it happened and how it can be prevented from happening again. That is all; a baby cannot be brought back to life, but parents can be given those kinds of reassurances and answers. That is really important to moving on and looking to some kind of future.

It upsets me to say this, but I have absolutely no confidence that lessons were learned in my case, and I know that many parents feel exactly the same. However, I am very pleased to participate again in this annual debate, because these things need to be said, and they need to keep being said until health boards and NHS trusts stop covering up mistakes and have honest conversations when tragedies happen, as sometimes they will. Parents who are bereaved do not want to litigate; they want answers. It is time that NHS trusts and health boards were big enough, smart enough and sensitive enough to understand that. Until mistakes stop being covered up, babies will continue to die, because failures that lead to tragedies will not be remedied or addressed. That is the true scandal of stillbirth, and it is one of the many reasons why Baby Loss Awareness Week is so very important, to shine a light on these awful, preventable deaths for which no one seems to want to be held accountable.