Baby Loss Awareness Week

Helen Morgan Excerpts

Thursday 19th October 2023 Commons Chamber

[Helen Morgan (North Shropshire) (LD)]

I beg to move,

That this House has considered Baby Loss Awareness Week.

I thank the Backbench Business Committee and all those who have supported this important debate. In particular, I thank the hon. Member for Sheffield, Hallam (Olivia Blake), who, unfortunately and unexpectedly, has been unable to attend. She sends her apologies to Mr Speaker for that. I also wish to thank the hon. Member for Truro and Falmouth (Cherilyn Mackrory), my co-chair of the all-party parliamentary group on baby loss. She is a font of inspiration, guidance and support, and I thank her for that. I joined the APPG shortly after being elected and became its co-chair earlier this year. I joined because many of my constituents had suffered the loss of a baby at Shrewsbury and Telford Hospital NHS Trust, and the Ockenden report on systemic failings there revealed that many women—indeed, whole families in Shropshire and the surrounding area—had suffered a devastating loss that was avoidable.

Baby Loss Awareness Week—which took place last week, while we were still in recess, but which we are marking with this debate—is an important moment to support any family who has lost their baby and to ask ourselves whether anything more can be done to prevent other families suffering this heartbreak. This time last year we debated the findings of the Ockenden report—most importantly, the need for safe staffing levels in maternity units across the country. One year on, I ask the Minister to update us specifically on the progress made and on the outlook for maternity services and safe levels of staffing in the future. Unfortunately, since the debate last year we have been starkly reminded that poor maternity care was not restricted to Shropshire. Dr Bill Kirkup has reported on his findings at East Kent and Donna Ockenden is currently reviewing issues at Nottingham, which threaten to be on an even greater scale than those at Shrewsbury and Telford.

Each time a scandal emerges, we promise ourselves that it will be the last time, but tragically that has not been the case so far. Far from being a localised issue, it seems that maternity services have been experiencing a crisis nationally. In 2022, 38% of maternity services were rated by the Care Quality Commission as inadequate or requiring improvement. The avoidable death of a baby is something we should be working to eliminate.

Earlier this year, I attended the launch of the joint report by Sands and Tommy’s joint policy unit on progress on saving babies’ lives. The headline of that report is that the Government are not on track to meet their target of halving stillbirths, maternal deaths, neonatal deaths and serious brain injury from their 2010 levels by 2025, and there is no target for further improvement beyond 2025. The report also showed that in 2021 there were 13 babies per day who were stillborn or died within the first 28 days of life across the UK. In 2021-22, nearly a fifth of stillbirths were found to have been potentially avoidable if better care had been provided, and two thirds of action plans created following the death of a baby are rated as weak. Too often, avoidable losses continue to occur as a result of care that is not in line with National Institute for Health and Care Excellence guidance. For example, data for England show that 40% of women and birthing people do not attend their antenatal assessment before 10 weeks’ gestation, as is recommended in the NICE guidelines.

Research must be the key to improving outcomes and saving more babies’ lives in the future, yet relatively little is invested in pregnancy-related research. For every £1 spent on maternity care in the NHS, only 1p is spent on pregnancy research. Worse, health inequalities are stark when we look at baby loss. Black babies are twice as likely to die in their first 28 days as white babies, and black ethnicity is associated with a 43% higher rate of miscarriage than white ethnicity. In England and Wales, in 2021 the stillbirth rate for women from the black African ethnic group was seven per 1,000 births, which would have to reduce by more than 60% in four years to meet the 2025 overall population target of 2.6 per 1,000 births. Stillbirths are almost double the level among people living in deprived areas in the UK than they are among those in the least deprived areas.

There is also a real lack of evidence in this area. Much of the national data is based on aggregated ethnic groups or broad categories of deprivation, which provide limited insights into individual lives. Despite the Government’s commitment to levelling up, there are no national targets and no long-term funding for reducing inequalities between ethnic groups or areas of deprivation. I know that the Minister has read that report and engaged seriously with these issues, and I urge her to consider its recommendations in full.

My constituents Kayleigh and Colin Griffiths, along with Rhiannon Davies and Richard Stanton from Telford, campaigned tirelessly for the Shrewsbury and Telford Hospital NHS Trust review, and I was pleased that they were each awarded an MBE earlier this year in recognition of their efforts to ensure that parents’ voices were heard and that babies born in future would be safer. They have reflected on the new concerns that have come to light and have written to the Secretary of State to request a public inquiry into maternity services in England, given the apparently alarming scale of the national problem. Unfortunately, they have not yet received a response to that letter. Will the Minister confirm whether the Secretary of State will be replying to that letter, and whether the Government will consider nationwide action to fully understand why maternity services have come under so much pressure and how to prevent avoidable baby deaths in future?

We should always remember that these are not statistics but the horrific experiences of women at their most vulnerable. A constituent wrote to me this week following her own experience at Shrewsbury and Telford, one about which Donna Ockenden’s team concluded that different management would reasonably have been expected to have made a difference to the outcome. My constituent said:

“My son was born 10 days overdue on 7th August 2007 in Shrewsbury hospital. Unfortunately, due to gross negligence by the trust that day I left their hospital with empty arms and a broken heart.”

Shrewsbury and Telford Hospital NHS Trust accepted all the findings of the Ockenden report and regularly reports its progress against the recommendations. I am in regular contact with the trust’s team, and they reported that 75% of the recommendations in the report had been delivered and assured, and that there is good progress on the remainder. Of the recommendations in the earlier first report, 88% have been implemented and assured, and I have also received assurances that staffing levels in the maternity service are at an acceptable level. However, Donna Ockenden also recommended immediate and essential actions for the whole of the UK in both her first and second reports. I hope the Minister will be able to provide us with an update on progress on those actions, particularly on safe staffing, training and culture within the maternity service.

I also want to consider those awful circumstances where the loss of a baby is unavoidable and the cause often unknown. In 2021, the cause of 33% of stillbirths and 7% of neonatal deaths was unclear. The all-party group on baby loss has heard devastating evidence from parents who have been left in limbo for months or even years waiting to find out why their baby died, because of a desperate shortage of perinatal pathologists. A survey conducted by Sands in 2022 found that delays in parents receiving post-mortem results have significantly worsened over time. More than a fifth of parents reported waiting up to six months or more for the result of their baby’s post-mortem.

In October 2022, an interim policy for the commissioning of perinatal post-mortems was adopted, which defines inclusion and exclusion criteria as to which cases will be offered a perinatal post-mortem. Since this policy was adopted, no audit of the impact has been undertaken, with NHS England acknowledging that communication of the interim policy has fallen short. Sands has received anecdotal evidence of consent takers being unaware of the new approach and it is concerned that that has led to parents not being fully informed about consent.

There are currently just under 50 full-time equivalent paediatric and perinatal pathology consultants in post in the UK, with an additional 15 vacant consultant posts. The number of current trainees is insufficient to fill these vacancies according to the Royal College of Pathologists. Will the Minister provide a clear commitment and timeline for the recruitment of perinatal pathologists, to ensure that no bereaved parent ever has to wait more than six months for post-mortem results?

It is obvious that staffing remains the single most important issue for maternity services. In a survey commissioned by the Sands and Tommy’s joint policy unit, 84% of midwives who were asked disagreed that there were enough staff around them for them to do their jobs properly. A decrease in staffing levels has been down to staff sickness rates over time and job satisfaction. In 2022, 63% of midwives in England had felt unwell in the past 12 months because of stress.

NHS England has recently published its long-term workforce plan and the Government have provided an initial financial commitment of £2.4 billion over the next five years to fund education and training. Will the Minister consider the importance of long-term recurrent funding, as well as investment in retention? Without that, there is a risk of losing valuable experience and skills in the existing workforce. The workforce plan models the number of future midwives required, but does not include other staff groups, which risks ignoring some of the areas and specialisms in the wider maternity and neonatal workforce, where staffing issues are most acute.

We all know there is no magic money tree, but it is a false economy to continue to deliver services that are potentially unsafe. According to Sands, the cost of harm from clinical negligence caused by NHS maternity services was £8.2 billion in 2021/22—60% of the total cost of harm from clinical negligence in the NHS and more than double what the health service spends on maternity care in the first place. The cost of failure is always so much higher than the cost of success.

In conclusion, while the Government’s commitment to the recommendations of the Ockenden report was welcome, there is a still a long way to go to deliver world- class maternity services and meet the Government’s own target of halving baby loss by 2025. Too often, harm continues to occur as a result of care that is not in line with nationally agreed standards. Listening to the voices and experience of families must be at the heart of policy, but most importantly we must ensure staffing levels are safe, so that no one leaves hospital with empty arms and a broken heart, where that might have been avoided.

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[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.

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[Helen Morgan]

I start by thanking the Minister. She has always engaged constructively and proactively with the all-party parliamentary group on baby loss, and I welcome her commitment to the pregnancy loss review and implementing its findings. It is clear that we still have some way to go, and I am sure that this time next year we will be asking for further updates on progress against the Ockenden review, but I thank her for her constructive approach.

On the contributions made by other Members, the hon. Member for East Worthing and Shoreham (Tim Loughton) made a good point highlighting not only the impact of baby loss on dads and the need to support them, but the wider issue of helping people who have lost their baby to understand why their baby died, whether that is perinatal pathology or getting a coroner’s inquest into what happened. That is so important, and I thank him for raising that issue.

The hon. Members for Truro and Falmouth (Cherilyn Mackrory) and for North Ayrshire and Arran (Patricia Gibson) shared their personal experiences, which were extremely powerful, and I am extremely grateful to them. They both highlighted important issues, such as the national bereavement care pathway and its roll- out, the importance of continuity of carer and the appropriateness of physical facilities to look after mums and dads who have just lost their baby. Finally, I want to touch on the culture of cover-up, which has come up in every review, and the importance of focusing not just on clinical professionals, but on management culture going forward. In conclusion, I thank everybody who contributed. It has been a useful way to recognise Baby Loss Awareness Week.

Question put and agreed to.

Resolved,

That this House has considered Baby Loss Awareness Week.