Maternity Commissioner

Helen Maguire 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.

--- Later in debate ---

[Helen Morgan]

I thank my hon. Friend for his intervention—he was quick off the mark. Yes, I agree that it will be useful to have a maternity commissioner to share those experiences and ensure that people learn from them.

The campaigners, Theo and Louise, have shared their heartbreaking experiences. I commend their work in securing this important debate. Liberal Democrats wish to be their allies. As a previous co-chair of the APPG on baby loss, I am all too familiar with the acute need for better standards of care for mothers across the country. I was also a member of the APPG on birth trauma when it was headed so ably by Theo Clarke, when the need for a maternity commissioner was first discussed and recommended. I am delighted to see the traction that this proposal has had thanks to the campaigning of Theo, Louise and many others.

Last month, the Lib Dems launched our maternity rescue package, which would guarantee high-quality care wherever people live and would make Britain the safest country in the world to have a baby.

[Helen Maguire]

I have a constituent who had a history of rapid births. She wanted the safety net and support of a home birth team alongside the community team, as recommended, but she was unable to have both teams involved. Does my hon. Friend agree that it is difficult to have confidence in a safe birth if the right medical support simply is not there?

[Helen Morgan]

My hon. Friend makes a good point. Patient voice—listening to women, understanding their wishes and understanding the risks that their wishes might represent and how to manage them best—is such a critical part of safe maternity care.

In drawing up our rescue package, I have drawn from my experience on the all-party groups on birth trauma, on maternity and on baby loss. There is so much common ground with the cause of the petitioners. We hope that they are buoyed by the fact that someone in Westminster is listening. With our package, a national maternity commissioner would oversee improved standards of care nationally, while a director of midwifery would be appointed in every maternity unit, alongside an extra 300 consultant midwives, to drive clinical excellence in each unit.

Our plans would invest £600 million to tackle these vital staffing requirements, but the NHS could save billions of pounds on maternal clinical negligence claims, which cost more than £1.3 billion in 2024 alone. Those huge clinical negligence costs have consistently been reflected in the findings of local and national reviews, but most importantly, the package would save babies’ lives and spare families the trauma of injury or worse happening to mum and baby at what should be the most joyous time of their life.

Liberal Democrats welcome the recent interim review by Baroness Amos. The findings of the review were devastating, showing that too many mothers are not receiving the level of care that they need, with devastating consequences for women, babies and their families. But this is the latest in a string of national and local reviews and inquiries, which have produced more than 700 recommendations. Those reviews, with their myriad but similar recommendations, illustrate why we need a maternity commissioner—someone who can bring together the learnings from past failings, along with the best practice from around the country, and oversee a step change in training and culture that will enable all the health professionals in maternity to work as effective teams and give women the personalised and high-quality care that is needed.

People across the country were truly shocked by the findings of Donna Ockenden’s review of the Shrewsbury and Telford hospital trust, which serves my constituents. The review found that the deaths of more than 200 babies could have been prevented. Over the years, I have heard—sometimes as a friend, sometimes as an MP—from traumatised and grieving parents, each with their own experience of birth trauma, injury to their baby or worse. They have told me how important it is to them that the reports and inquiries spark the vital change that is needed, and do not lead only to warm words from politicians followed by decades of gathering dust on the shelves of the Department of Health.

Since the Ockenden review, the Shrewsbury and Telford hospital trust has accepted and taken steps to implement almost all the immediate and essential actions that Donna Ockenden recommended. While that process has not been perfect, it has clearly been conducted with appropriate focus. The latest CQC rating for maternity at SATH is good, showing that with the right recommendations and leadership, positive change can happen. The team at SATH should be commended for that achievement. They demonstrate the value of focusing on the steps needed to get care right.

As we found out subsequently, however, unsafe maternity care was not unique to Shropshire, or indeed to Morecambe, East Kent or any of the other places about which we have heard such awful stories. We know that women all over the country are still not receiving the care they need. None of the services that the Care Quality Commission inspected in its national review was rated outstanding. Some 65% of maternity units were unsafe for women to give birth in. It is a scandal that mothers in this country have to settle for potentially dangerous levels of care at what should be one of the happiest moments in their life.

The introduction of a maternity commissioner is not a quick fix, but a commissioner would provide the leadership required for serious change to the way women and staff on maternity wards are listened to. That commissioner could look at disparities in maternity care and the poorer outcomes that we see for black and Asian women and those in deprived communities, and drive the change needed to make having a baby safe, no matter what your background is. Other improvements are needed, too.

Our proposals are to guarantee specialist doctors on every maternity unit 24/7, and one-to-one midwifery care for every woman during labour to respond to the desperate need for safe staffing highlighted in each of the reviews and in the inquiries by the all-party groups that deal with maternity care. Previous research found that 73% of maternity units in England do not have a consultant present at night, despite most births taking place outside working hours. Many negligence claims for poor maternity care are linked to failings in care outside regular working hours.

The proposals come alongside a new capital investment programme to fix crumbling maternity units in need of urgent repair and to deliver new dedicated bereavement suites. We would start with the 7% of maternity units that are at risk of imminent breakdown, and would restore the 42% of units in need of major repairs. These crucial steps come alongside many other proposals to improve staff training, to invest in bereavement support, neonatal specialists and pre-conception services and to eliminate maternal health disparities.

It is really, really, really important to say that the vast majority of babies are delivered safely, even when things do not go to plan. But we should not dismiss those instances where they go wrong, and we should be tireless about making the improvements required. I congratulate the campaigners on the success of the petition so far. I continue to urge the Government to demonstrate that recommendations will be turned into actions, and that the cries for help from countless mothers and families will be listened to.