Reducing Baby Loss

Lilian Greenwood Excerpts

Tuesday 20th July 2021 Westminster Hall

[Lilian Greenwood (Nottingham South) (Lab)]

I would like to focus on the progress towards safe births at my local trust. I wish I did not need to speak in this debate; I wish that Nottingham’s hospitals, Queen’s Medical Centre and Nottingham City Hospital, were safe places to have a baby. That is what parents in my constituency need and have a right to expect. But right now, that is not what they are guaranteed, as the trust’s chief executive admitted a few weeks ago:

“We fully accept that, although our staff are passionate about what they do, we have not created an environment where these same staff can provide a positive and safe experience for every family in their care, every time.”

A recent investigation by The Independent and “Channel 4 News” found that since 2010, there have been 201 clinical negligence claims against the trust’s maternity services—almost half lodged in the past four years. In those claims are 15 deaths, 19 stillbirths, 46 cases of brain damage and 18 cases of cerebral palsy. The trust has already paid out £79.3 million in compensation but, of course, the human costs are much higher.

In September 2019, Wynter Sophia Andrews was born at the QMC. She died 23 minutes later. It was only after the healthcare safety investigation branch’s findings were published that the trust admitted failings and that earlier intervention would have avoided Wynter’s death. Wynter’s death was the subject of an inquest, and in her verdict the coroner was highly critical of Nottingham University Hospitals NHS Trust. The coroner said that Wynter would have survived if action had been taken sooner. I will not read the detailed quote from the coroner, but she said that the incident reports and staff accounts demonstrate that

“this was not an isolated incident. An unsafe culture had been allowed to develop as these systemic issues had not been adequately addressed by the leadership team.”

During the inquest, it also emerged that a letter from maternity staff at the trust was sent to the hospital board in 2018 asking for help and raising serious concerns about safety.

Following the coroner’s report, NUH maternity services were subject to unannounced inspections by the Care Quality Commission, which published its report last December. The inspector said:

“During the inspections, several serious concerns were identified. For example, risk assessments which women were expected to have undertaken during their care were not always completed in line with national guidance. Staff did not always use a nationally recognised tool to identify women at risk of deterioration. n addition, the service did not always have enough midwifery staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix but were limited to the resources available. Following this inspection, maternity services at Nottingham City Hospital and Queen’s Medical Centre are rated Inadequate overall. The services are rated Inadequate for being safe, effective and well-led. Maternity services were previously rated Requires Improvement.”

The worst thing about the situation is that it did not need to be like this. When I read Gary and Sarah Andrews’s account of Wynter’s death, I felt sick—not just because it is tragic and heart-breaking for anyone to lose a much wanted baby, but because there were striking similarities to an earlier case.

My constituents Jack and Sarah Hawkins’s daughter was born dead at Nottingham City Hospital in April 2016. Harriet was a healthy, full-term baby. She died as a result of a mismanaged labour. The trust initially claimed that her death was caused by an infection. Jack and Sarah were told to “try to move on.” It was only thanks to their incredible courage and determination to fight for the truth that the trust was finally forced to admit gross negligence.

I sat with Jack and Sarah in a meeting with the trust’s then chief executive, with photos of Jack, Sarah and their dead daughter on the table in front of us. He apologised and promised that the trust would learn the lesson. Following the coroner’s verdict in Wynter Andrews’s case, I read the comments from senior staff at the trust, apologising and promising to learn the lessons. They were the exact same promises that I had heard more than three years earlier.

Gary and Sarah Andrews wrote to me in March. They said:

“All we want is for other parents to be taking their children home.”

They, Jack, Sarah and other parents are calling for a public inquiry into maternity services at Nottingham University Hospital Trust. I am sure that the Minister will tell me, and them, to put their faith in the Care Quality Commission and the Healthcare Safety Investigation Branch, but they do not share her confidence that that will be effective. In Harriet’s case, there were numerous investigations, both internal and external, but things did not change or did not change enough.

As the Health and Social Care Committee report notes,

“Involving families…is a crucial part of the investigation process…Families must be confident that their voices are heard and that lessons have been learnt to prevent the tragedy they have endured being repeated.”

When I met the CQC investigation team in April, I was shocked to hear that they have not contacted bereaved parents or sought to hear their views. They claimed to be unaware of Harriet Hawkins’s case.

When I raised concerns with the Minister, her reply contained the news that NHS England, NHS Improvement and the clinical commissioning group are

“finalising the terms of reference for an independent thematic review of maternity cases going back to 2016”.

As Jack Hawkins told me, this has happened without any input from families. The review was due to go back to only 2016, although we know there were many improperly investigated baby deaths and harmed babies before then. That is why they want a truly independent review, not one where it is too easy to suggest that Nottingham University Hospital Trust has a hand in it, and where parents of dead and damaged babies are ignored and excluded from the process of deciding what needs looking at.

I hope that when the Minister meets me and other MPs she will also hear from the parents affected by some of these tragic failures to improve maternity services at Nottingham University Hospital Trust. I look forward to hearing her response both today and on that occasion.

--- Later in debate ---

[Justin Madders (Ellesmere Port and Neston) (Lab)]

It is a pleasure to serve under your chairmanship this morning, Mr Gray. I thank the hon. Member for Truro and Falmouth (Cherilyn Mackrory) for securing today’s debate and the compelling way she spoke both today and in the debate last November. I was not present for that debate, but I read it over the weekend. I never thought that reading Hansard would bring a tear to my eye, but the way that she and many other Members spoke in that debate was incredibly moving and powerful. Today, she said some very important things that we all need to reflect on. She talked about the staff who cared for her during her difficult times, and she used the words “kindness, compassion and professionalism”, which are absolutely the qualities that we need in our NHS workforce in this particularly sensitive area. We should all put on record our thanks to those who do incredible work in incredibly difficult circumstances.

The hon. Member for Truro and Falmouth also mentioned the Select Committee report and noted that progress had been good, but it was from a low base. As a number of Members said, variation still exists across the country. The hon. Member talked about her six priorities. A number of Members talked about some of them, but she set out clearly where we need to do more about staffing the shortfalls. She made an important point about providing not just training, but the back-filling of positions while staff go on training. She also made an important point about parents’ involvement and engagement with such issues, because those who have been through awful experiences have the best input to give us on how to make it a little easier for those who have to face it in the future.

Clinician confidence to report issues was another important point that several Members raised. It is important that clinicians feel able to raise concerns and that they are acted on, which does not always happen. Like most Members, the hon. Member for Truro and Falmouth mentioned continuity of care and the importance of more research. One of the things that parents want to know is why this happened to them.

[Lilian Greenwood]

Each year, 1,200 babies are stillborn, and a third of those die after a full-term pregnancy. We know how important coroners’ inquiries can be in getting to the truth and preventing future deaths, but they are currently unable to investigate stillbirths. Does my hon. Friend think it would be helpful if the Government now responded to the 2019 consultation on extending coronial powers to cover stillbirths, so that some of that important investigative work can contribute to attempts to reduce the number of stillbirths in this country?

[Justin Madders]

My hon. Friend is absolutely right. Her speech gave a very clear example of how that can be of benefit not just to the parents, but to the wider system. Parents will always want to know why this has happened to them. It will not always be possible to give an answer, but if we can do more to look at that, it would be of great benefit.

My hon. Friend the Member for Sheffield, Hallam (Olivia Blake) spoke in November’s debate as well as today, and her contribution was incredibly moving. She raised the issue of research and the need for more funding to be brought into this area. Like many Members, she talked about the huge inequalities in perinatal outcomes. She also raised an important point about data collection, which will of course inform policy moving forward. It is not just about collecting data, but about collecting it in a timely manner and accurately.

The hon. Member for Darlington (Peter Gibson) mentioned the experience of his constituents Claudia and Andy, and he made a very important point about statutory bereavement leave, which we ought to look at again.

The comments of my hon. Friend the Member for Nottingham South (Lilian Greenwood) about her own trust, the death of baby Winter, and her constituents Jack and Sarah, who had a similar loss with Harriet in 2016, were telling. That really was a case of many of the issues being repeated, and it sounds to me as if the trust has not done enough to learn the lessons. My hon. Friend also made a vital point about parental involvement in the review process. It seems to me that 2016 is an arbitrary date, and I encourage the Minister to engage in a dialogue with parents to make sure that the scope of the review is as wide as it can be.

My hon. Friend the Member for Putney (Fleur Anderson) made an excellent speech, highlighting just how far we still have to go with obstetrics and how inequalities in outcomes still exist. She made the important point that these issues need to be addressed in conjunction with those who have experienced a loss. Parental involvement is a theme that has come through several times today. She also made a very important point about the culture, which is not always the best for raising concerns and learning from past experiences.

My hon. Friend the Member for Liverpool, West Derby (Ian Byrne) also mentioned continuity of care and the workforce challenge, something that most Members raised. He said that postcode, ethnicity and income should not be telling factors in outcomes. He also told a very moving story about one of his constituents, who suffered their own loss. Unfortunately, it seems that the failings that were identified there will resonate with many trusts.

My hon. Friend the Member for Luton North (Sarah Owen) spoke incredibly movingly today, as she did in the previous debate. She brought home how difficult it is for those who have successful subsequent pregnancies still to have to deal with previous losses, which are still on their minds, as one would expect. Again, continuity of carers and workforce issues were raised. She made a very important point about vaccines and the admissions that we have seen in recent weeks of pregnant women with covid. A very important point was put to the Minister about the priorities for booster jabs, which I hope she will address. The point my hon. Friend made most powerfully was about the three miscarriage rule, and the way she spoke brought home how cruel it is. It really does need revisiting.

Finally, the hon. Member for Strangford (Jim Shannon) gave a very heartfelt speech. Again, he raised a number of issues about staffing.

I am nearly out of time, so I will make just a couple of points. A number of Members touched on issues that have arisen during the pandemic. We know that there has been reduced access to face-to-face appointments. Partners have sometimes been excluded, leaving women to receive this terrible news on their own. That has obviously been deeply isolating for mothers, but also for fathers. Virtual appointments just do not allow for the compassion and assurance that is really needed in those difficult moments. Of course, even if the woman has had her partner with her, the wider family has not always been able to comfort them during those difficult times.

We know that, for those who have had a loss, time is of the essence. There is a direct correlation between when someone receives mental health support and how long it is needed. A survey by Sands found that nearly two thirds of bereaved parents who felt they needed psychological support were unable to access it on the NHS. We really need to do much better on that.

Finally, I want to take a few moments to recognise the fantastic work that the more than 60 charities that collaborate together in this area do and the way they support anyone who has been affected by pregnancy loss or the death of a baby. They work very constructively with health professionals to improve services and reduce deaths. I also pay tribute to Donna Ockenden and her team for the work they are undertaking. There is no doubt that the more work they do, the more it becomes apparent that there is an awful lot more to do.

It is now approaching five years since we had the first of what has become an annual debate on baby loss in the House. Those debates have seen the House at its best. Members recall their own experiences, and no one should underestimate how difficult that must be. That plays a vital role in helping to inform policy, but it also says to those who may be going through these awful experiences that they are not alone.