Maternity Commissioner

Jess Brown-Fuller Excerpts

Monday 20th April 2026 Westminster Hall

[Jess Brown-Fuller (Chichester) (LD)]

The hon. and learned Gentleman is making an important point about the disparity in the guidance. If there is someone at the top of an NHS trust who is passionate about maternity care, that is more likely to trickle down, but that is not the same in every trust, and therefore we can end up with a postcode lottery. In Chichester, mothers going to give birth would have a totally different experience if they went to Chichester, Guildford or Portsmouth because they are three totally different trusts with totally different guidance and rules about when mothers should present or the sort of treatment they should get at hospital. Does the hon. and learned Gentleman agree that introducing a maternity commissioner would give us strategic oversight across the country of the experiences that mothers should expect to have?

[Tony Vaughan]

Certainly, the petition is clear that without expert, national-level oversight, there is no way of turning that thicket of different guidance and frameworks into a coherent, enforceable standard of care. Whatever structural change the Government put forward has to do that job. I spoke to my constituent Jo Page earlier, and she told me that there are people in Folkestone and Hythe who are going to Tunbridge Wells to access maternity services because of their concerns about the local standards of care. Obviously, that has to be fundamentally addressed.

The powerful evidence from the various maternity investigations that we have seen show that when everyone is responsible, nobody is accountable. Appointing a maternity commissioner could well mean that there is somebody with whom the buck stops—a dedicated expert responsible for turning the 750 recommendations, or the 87 guidance documents, into a single national maternity strategy and ensuring that it is implemented. That is not the only way that that could be done; Baroness Amos will shortly publish her report on the national maternity and neonatal investigations in NHS services. The petitioners strongly believe that her report should commit to a maternity commissioner and a maternity strategy. I look forward to hearing from the Minister how the Government currently view that proposal. I also ask her to commit to providing an update on which of the previous recommendations committed to may be taken forward.

In conclusion, the Government’s recent decision to introduce a women’s health strategy is hugely welcome and is an important acceptance that women’s health has been neglected for far too long. The petitioners strongly believe that it would make a real difference to women giving birth if that strategy encompassed a maternity commissioner with the authority, expertise and focus to end the postcode lottery in maternity care and break the cycle of avoidable harm once and for all.

--- Later in debate ---

[Lizzi Collinge (Morecambe and Lunesdale) (Lab)]

It is a pleasure to serve under your chairship, Sir Alec. I thank my hon. and learned Friend the Member for Folkestone and Hythe (Tony Vaughan) for introducing this important debate.

It is hard to fathom but, over the course of this speech, at least four babies will be born in England—they will come into the world, their tiny hands stretching out and a whole future beginning for them with their first breath. The births of my children were among the most significant moments of my life, as is the case for most parents, but alongside the joy comes something that I think every birthing parent will recognise: just how vulnerable you are in that situation and how frightening childbirth can be. You are placing your life and your baby’s life in the hands of others, in the hands of chance and in the hands of the brutal reality of natural processes.

I first became involved in maternity advocacy after the frankly quite awful birth of my first child in 2014. Only when that happened did I realise how much harm had been done to someone close to me when she gave birth in 2011. I remember apologising to her with a newborn in my arms: “I’m so sorry; I had no idea how bad it is.” This has happened to women up and down the country. Today, I represent Morecambe Bay, where both those births took place, and where baby Ida Lock was born and died in 2019. Ida and her parents are always on my mind when we talk about issues such as this.

I feel obliged to say that the vast majority of maternity care is safe. We talk about all the failings and all the horrors that women have seen, but I do not want that to frighten families. We have to accept that the worst tragedies are exceptions, but the experience of parents who have seen avoidable harm to themselves and their babies is the reason we are here today debating the pros and cons of a maternity commissioner.

I will be honest: I do not necessarily have fixed views on this. It has been really interesting to hear colleagues speak, and I look forward to hearing more. I am also very interested in the outcome of Baroness Amos’s investigation. But we cannot just keep trying to learn lessons; we need to take action right now. We have had review after review and inquiry after inquiry, and yet here we are.

[Jess Brown-Fuller]

The hon. Member is making a powerful speech, and she is absolutely right. We had the Bill Kirkup review, which made multiple recommendations; across all parties, the House said, “Now we need to implement those recommendations,” but that never happened. Then we had the Donna Ockenden review, which contained immediate and essential actions; we need to implement those, but the Government have not come forward and said that they will make them mandatory. Now we have Baroness Amos’s review. Does the hon. Lady agree that this must be the last review, for the sake of every single mother who has come and every single mother who is to come, so that they know that they are being well supported when they go into hospital settings?

[Lizzi Collinge]

I absolutely agree. There is work to do to prioritise the actions that have come out of all those inquiries, because trying to do too much will lead to it all being done badly. There must be a real focus on what will make the difference to women’s safety and experience.

Countless national and local maternity reports have revealed persistent issues with care, a failure to listen to expectant mothers, staffing pressures, a lack of transparency and institutional cultures that have encouraged cover-up. That is against the background of increased medical complexity in pregnancy and birth, wider aspects of public health having worsened, and the racism and misogyny that still permeates our society.

These failures are a long time in the making. Failed regulation contributed to the historic problems at Morecambe Bay—and that was under a Labour Government. Structural changes to our care system and wider society under successive Conservative Governments have impacted care. Due to austerity, we had a £37 billion capital investment shortfall in the 2020s compared with our peer countries. We know that increased poverty affects maternal and neonatal mortality, and as a nation we have become more poorly over the past 15 years. It is now on us and the Government to fix the problem.

As a member of the patient safety all-party parliamentary group, as well as through my own work as a constituency MP, I have seen that tragedies are often partly or completely avoidable, whether through effective diagnostics, timely or better treatment, or simply listening to women when they say that something is wrong. The consequences of these failures are devastating. A study by the Royal College of Obstetricians and Gynaecologists showed that up to 75% of pre-term babies who died could potentially have been saved with different care. Even when the worst is avoided, bad experiences can leave lasting damage. They can erode trust in services and make families more anxious about seeking care in the future.

I want to touch on a couple of aspects of this issue that have not had the concerted operational effort put into them that they ought to have had. The first is the conditions that midwifery and obstetric staff work in, including the wider picture of the health of the nation. Most midwives, doctors and support staff are doing their absolute best in challenging circumstances, and most people go into maternity care because they want to deliver babies safely into this world and support families. They often go above and beyond, but they are being stretched too thin by the demands of their jobs. They are looking after ever more complex cases on every shift, and in 2023 alone, midwives and support workers put in over 100,000 hours of overtime. Even hospitals that are rated highly for maternity care feel the strain, with staffing gaps leading to interrupted handovers, missed checks and limited time for training. Over time, that pressure leads to burnout, staff leaving, and the loss of the experience that the system depends on. When the system is stretched like that, it is staff and patients who feel the consequences. I hope that the Minister will ensure that while we drive down waiting lists in elective care, we support maternity staff, improve their work environment and do not lose sight of the wider improvements to public health that we need to make to reduce complexity and comorbidities.

The second thing I want to talk about is culture, particularly the ability of staff to speak up, the need for brave and open leadership, and the need for lessons truly to be learned. I am not saying that is easy to do—it is quite tricky, and it takes concerted effort and skilful leadership—but culture simply means, “The way we do things around here.” It can be a tangible thing that we can affect. Unfortunately, long-term failures and the spotlight that comes with them can cause staff to feel under attack, defensive and unsupported. Even where they have not been part of any particular case, staff groups can become entrenched. During the problems at Morecambe Bay and since, we have found that people working in opposition to each other in entrenched staff groups has caused huge amounts of harm.

Poor leadership compounds the effect. I have spoken many times about the harm caused by cultures of silence, where staff do not feel able to come forward to raise concerns, problems are not addressed head on, and families are left without proper answers when things go wrong. We need to create environments where people are able to speak up, raise concerns early and be open when mistakes happen, because if staff do not feel safe to tell the truth and fear being blamed or punished, problems are hidden instead of being fixed. More than that, staff need to be supported when they raise a concern or even when they cause harm, because staff do not listen to what the leadership say; they see what they do, look at their actions and behave accordingly.

To be clear, human beings will make mistakes, and patients will be harmed by those mistakes. That is inevitable. Not all cases of harm can be prevented, but they can always be learned from. In any organisation, culture is set from the top. The leadership have to show through actions that concerns are taken seriously and that no one will be penalised for speaking honestly. Working as a maternity advocate, I was shocked that organisations that are meant to be care organisations would respond to a bereaved family not by reaching out, caring for them and holding them, but by keep them at arm’s length, lying to them and even, when it came to coroner’s inquests, being adversarial. It beggars belief.

Linked to that is the fact that families often feel the need to take legal action simply to get answers. That costs huge amounts of money, still sometimes does not get them answers, and sets up an adversarial approach that can cause further harm to families. I hope that the Public Office (Accountability) Bill, also known as the Hillsborough law, will shift the legal risk for organisations. The current legal risk to many hospital trusts appears to be telling the truth—that seems to be how they see it. I hope that the new law will shift the legal risk so that it is far riskier to obfuscate than to be candid.

There are so many different aspects of maternity safety that I could talk about all day, such as the way that “normal” birth culture still permeates the education of our midwives and some practice, despite having been shown to be harmful. The wider culture around birth seems to say that it must be a joyful, wonderful experience at all times, when in reality it is messy, brutal and quite often unpleasant, even when it all goes well.

We should be learning from other countries. For example, Japan has no-fault compensation for profound cerebral palsy. That separates the process of giving compensation from the process of investigating what happened and what went wrong. It appears to have lowered the legal costs associated with maternity care, but more importantly, it seems to have reduced the number of babies born with profound cerebral palsy.

We all know that maternity care needs to be improved in this country, whether through the appointment of a maternity commissioner or actions such as implementation of recommendations in the Amos review. I thank my colleagues for their contributions, and their constituents for sharing their stories. To make maternity care safe, we need to ensure that services are properly staffed, creating the conditions for safe care, where handovers can be done properly and staff have time to do their jobs well and are supported to rest and recover. That also means making sure that women are listened to, that concerns are taken seriously and that, when things go wrong, they are handled with honesty and care. It means accountability for leaders as well as frontline staff. I urge the Minister to consider whether the leadership of a maternity commissioner can give us the change that our constituents deserve.