Civil Partnerships, Marriages and Deaths (Registration Etc.) Bill

Lilian Greenwood Excerpts

2nd reading: House of Commons
Friday 2nd February 2018 Commons Chamber

[Lilian Greenwood (Nottingham South) (Lab)]

Thank you, Mr Deputy Speaker. I will attempt to keep my contribution concise. I congratulate the hon. Member for East Worthing and Shoreham (Tim Loughton) on bringing forward his comprehensive Bill. I know that he has wanted to act on these matters for a really long time, so this is a real tribute to persistence and determination. I support the Bill in total, but I am going to confine my comments to the issues addressed in clause 4, which deals with extending the powers of coroners to enable them to investigate stillbirths. This will make a difference to many families who need to know why their baby died. Even more importantly, it will ensure that lessons are learned and improvements are made so that other parents are spared the horror of losing a baby. I acknowledge the important work done by the Secretary of State for Health in acting to tackle avoidable harm and death through his maternity safety strategy. I welcomed his support for this Bill when he made a statement to the House on 28 November last year, in which he said:

“I will work with the Ministry of Justice to look closely into enabling, for the first time, full-term stillbirths to be covered by coronial law”.—[Official Report, 28 November 2017; Vol. 632, c. 179.]

That was an important and welcome development.

Mainly, though, I am here on a Friday to speak for Harriet Hawkins, because she will never be able to speak for herself. Indeed, she never got to draw breath, and, as the hon. Member for East Worthing and Shoreham has explained, that is significant. I am also here to support my incredible and courageous, but heartbroken, constituents, Jack and Sarah, Harriet’s parents. Their fight for the truth has been so dreadful and so unnecessarily painful that we in this House must act to ensure that others do not have to go through the same thing.

Let me explain what happened to Harriet, and Jack and Sarah, and how it could all have been so different. Harriet was Jack and Sarah’s first baby. There were no problems in pregnancy, and Sarah was considered low risk. She began to experience contractions one day after her due date on 11 April 2016. She was in labour for five days before Harriet was eventually delivered. In that time, Jack and Sarah made 10 phone calls and two visits to the hospital, the Queen’s Medical Centre. Each time, Sarah was assessed, reassured and sent home. When she was finally admitted—to Nottingham City Hospital, because QMC was full—an ultrasound revealed that Harriet had died. We might think that things could get no worse, but sadly, we would be wrong. Sarah was left struggling with an over-long labour, and Harriet was delivered more than nine hours later. In the following days, the only contact Sarah and Jack had with Nottingham University Hospitals NHS Trust was with the bereavement midwife. Each time, they explained that Harriet’s death was due to numerous errors. They expected to be contacted as part of an investigation, but that did not happen.

I should say that both Jack and Sarah work for Nottingham University Hospitals NHS Trust. Jack is a hospital consultant—a clinical director in NHS Improvement—and Sarah is a senior physiotherapist. They had an understanding of what they should expect. They knew that something had gone horribly wrong, and when they were told that a post-mortem revealed that Harriet’s death was caused by an “infection”, and told to “try to move on”, they refused to have their concerns dismissed. Following repeated requests, they met representatives of the NUH trust in July 2016. The trust said that it had carried out an investigation—without Jack and Sarah’s involvement—and concluded that there were no errors and that Harriet’s death was down to an infection. As an expert in infections, Jack was able to challenge this conclusion, and he and Sarah demanded an external review. The hospital conceded, and Jack and Sarah met the external review team in August 2016. Following that meeting, Harriet’s death was upgraded to a serious untoward incident, 159 days after she died. That should have happened within 72 hours.

In December, Jack and Sarah were sent a draft report to check for accuracy. It stated that

“Harriet’s death was directly contributed to by five things”.

That conclusion meant a great deal to Jack and Sarah, but when the final serious untoward incident report was circulated, the conclusions had been watered down, stating that

“Harriet’s death might have been avoided if”

certain other things had happened. To Jack and Sarah, this significant change smacked of a cover-up, and a refusal to learn from the handling of Harriet’s birth. The trust would not explain why the investigation team had changed its conclusions.

Dissatisfied with the handling of the investigation, Jack and Sarah contacted the clinical commissioning group, which organised a new external review team to conduct a second serious untoward incident investigation. That report was published in December 2017, and it said that there were multiple missed opportunities for intervention and appropriate monitoring earlier in the labour. Had one of those opportunities been taken, it is likely that the labour would have been substantially shortened, with any foetal compromise recognised on CTG. It is therefore likely that intrauterine foetal death would not have occurred:

“The overall conclusion of this investigation was that the death of baby H was almost certainly preventable.”

I do not know how many babies have died or been harmed since Harriet’s death in April 2016, or whether those deaths or injuries could have been avoided if the lessons from Sarah and Jack’s case had been identified earlier. I also do not know how many babies died before Harriet due to similar failings of care, which would have prevented her death had they been identified. Opportunities were very clearly lost, and without Sarah and Jack’s incredible fight there would have been no learning from Harriet’s death.

Sarah and Jack wrote to me earlier this week:

“We have always said had we not been clinicians we would not be here today, fighting. We would have believed the flawed internal report and the flawed initial external report. It has taken us almost two years to get an independent review. This should not be the responsibility of grieving parents to push for.

An external review cannot be deemed to be independent, like in our example. It will not provide the honesty and openness of the coroner’s court. It will not provide the follow through in learning to prevent other baby deaths.”

[Martin Whitfield (East Lothian) (Lab)]

I am grateful for my hon. Friend’s testimony. Does not this case clearly highlight the unique nature of the coroners’ courts, which provide the facilities and the vehicle to investigate such matters sympathetically, supportively and with an ability to get to the truth?

[Lilian Greenwood]

My hon. Friend is entirely right. The role of coroners is incredibly important, and there are a number of reasons why coroners are the right people to investigate such deaths. First, why should a baby’s death be treated differently from any other death? The coroner is an independent judicial office holder, and therefore the inquest will be truly independent and transparent. The coroner can address local issues at a particular hospital or unit, and they can refer to other statutory bodies, including the Care Quality Commission.

If a coroner makes a “prevent future deaths” report, it can be monitored closely. The family will be able to participate fully in the process, and not merely be consulted, and they will be able to have legal representation. The family will be able to attend the inquest to ask questions of the clinicians and managers concerned in the care, and they will receive full disclosure of all documents and policies in advance. A coroner’s inquest is heard in public, which ensures transparency of process and decision making. A coroner can of course recognise trends and, if necessary, impose improvement orders on provider organisations.

Jack and Sarah are concerned that the Bill commits to review, not to a definite change in the law, so I hope the Minister will listen carefully, acknowledge what the Secretary of State for Health and Social Care has already said and not let down my constituents.

Speaking in the media, Jack and Sarah said that they want to make their daughter proud. They surely make us all proud. We owe it to them to make this change in the law. Please support this Bill.

Civil Partnerships, Marriages and Deaths (Registration Etc.) Bill

Lilian Greenwood Excerpts

3rd reading: House of Commons & Report stage: House of Commons
Friday 26th October 2018 Commons Chamber

[Tim Loughton]

I am in a generous frame of mind this morning, and rather than their saying sorry, we should be saying hurrah that we are now doing something about it—[Hon. Members: “Hurrah!”] I do not know how Hansard will treat that.

The third aspect of the Bill relates to the production of a report on the registration of pregnancy loss. Again, clause 3 has already achieved its objective, partly in the light of our Second Reading debate, which we had back on 2 February, when we were all moved by the extraordinarily touching personal testimony of the hon. Member for Washington and Sunderland West (Mrs Hodgson) about her own experiences—I wonder whether she will draw her attention away from her mobile phone, because I know she would like to listen to this tribute and not be distracted. As a result of the strength of feeling in the speeches and the subsequent response from our constituents, the then Health Secretary—he is now Foreign Secretary—said, “Well, actually I think we just need to get on with changing the law.” A group was set up with a mandate to see how we could change the law to acknowledge in some way those births that are stillborn but happen, by whatever quirk, to fall below the 24-week gestation line and are therefore not recognised in the eyes of the state. The situation has brought huge distress to parents who are already in distress at the trauma of losing a child. The fact that they happened to lose that child at 23 weeks and six days means that, in the eyes of the state, that child never existed and is classed as any other baby loss. In saying that, I in no way diminish the trauma of all baby loss, but there are so many examples of this.

My constituent Hayley Petts first brought this matter to me, and she served on the working group with the hon. Member for Washington and Sunderland West. The group has been discussing many aspects of how the law can be changed and has also thrown up a lot of problems about how we go about changing the law. Should we have a universal certificate for all baby loss, for example? Should the scheme be voluntary or mandatory? Should it be subject to medical verification, as is the case under the Australian scheme, and should it be retrospective? There is then the whole thorny issue of how we avoid getting into the minefield that is abortion and other forms of termination. The Bill has done its job before it has become an Act because such work is going on under the aegis of the Department of Health and Social Care, and I hope we will have some results in due course.

[Lilian Greenwood (Nottingham South) (Lab)]

I congratulate the hon. Gentleman on bringing his Bill to Third Reading. On clause 4, does he agree that when parents lose a child—a healthy full-term baby—as my constituents Jack and Sarah Hawkins did, they should not have to fight to get answers? A coronial inquest might provide them with independent, public, open and honest answers so that they can concentrate on grieving, rather than having to fight to get to the truth of what happened.

[Tim Loughton]

I am grateful to the hon. Lady because she pre-empts my clause 4 moment. The fourth, and very important, component of this Bill, which is addressed in clause 4, is coroners’ investigations. She participated in earlier debates and worked very helpfully with me and others to move this important issue up the agenda. I am grateful for her contribution.

Clause 4 will allow part 1 of the Coroners and Justice Act 2009 to be amended. That is not easy, and the matter is slightly complicated by the fact that it falls under the jurisdiction of both the Ministry of Justice, which is responsible for coroners, and the Department of Health and Social Care, which is responsible for healthcare in relation to baby loss. I must pay tribute to some very helpful and proactive support for this measure by MOJ officials. I had a very helpful meeting with the Under-Secretary of State for Justice, my hon. Friend the Member for Charnwood (Edward Argar), who I am glad to see is present on the Front Bench. He was a great champion of many of the Bill’s provisions when he was just a commoner on the Back Benches and added his name to many of the measures I have been trying to get through today.

The Minister has confirmed that an immense amount of work has gone on at the Ministry of Justice. There are issues still to be resolved, such as whether coroners should have the power to investigate all stillbirth loss or should concentrate, which I think is practically the better approach, on full-term baby loss, when there are the fewest excuses or reasons for stillbirths to happen. Also, should this be mandatory or effectively subject to parental veto? There are serious problems with that, as there are some cases in which a stillbirth may have been connected to domestic violence and some sort of cover-up may be wanted, so I think we are coming to the view that the scheme should be mandatory. Should there be specialist coroners or should all coroners have the ability to investigate? Of course, there are also capacity constraints. The fact that a lot of work has been going on in the Department in the last few months shows that this can be done.