Ockenden Report

Lindsay Hoyle Excerpts

Wednesday 30th March 2022 Commons Chamber

[The Secretary of State for Health and Social Care (Sajid Javid)]

With permission, Mr Speaker, I would like to make a statement on the Ockenden report. The independent review was set up in 2017 in response to concerns from bereaved families about maternity care at Shrewsbury and Telford Hospital NHS Trust. Its original scope was to cover the cases of 23 families, but since it began, sadly, many more families have reported concerns. Due to this tragically high number of cases and the importance of this work to patient safety, early conclusions were published in an initial report in December 2020. We accepted all the recommendations of the first report, and the NHS is now taking them forward.

Today, the second and final report has been published. This is the one of the largest inquiries relating to a single service in the history of the NHS. It looks at the experiences of almost 1,500 families from 2000 to 2019. I would like to update the House on the findings of the report, and will then turn to the actions that we are taking as a result of it.

The report paints a tragic and harrowing picture of repeated failures in care over two decades, which led to unimaginable trauma for so many people. For these families, their experience of maternity care, rather than being of moments of joy and happiness, was one of tragedy and distress. The effects of these failures were felt across families, communities and generations. The cases in the report are stark and deeply upsetting. In 12 cases where a mother died, the report concludes that in three quarters of them, the care could have been “significantly improved”. It also examined 44 cases of HIE—hypoxic ischaemic encephalopathy—a brain injury caused by oxygen deprivation. Two thirds of the cases featured “significant and major concerns” about the care provided to the mother. The reports also states that of almost 500 cases of stillbirth, one in four was found to give rise to major concerns about maternity care that, if managed appropriately, “might or would” have resulted in a different outcome.

When I met Donna Ockenden last week, she told me about basic oversights at every level of patient care, including in one case where important clinical information was kept on Post-it notes, which were swept into the bin by cleaners, with tragic consequences for a newborn baby and her family. In addition, there were repeated cases where the trust failed to undertake serious incident investigations; and where investigations did take place, they did not follow the standards that would have been expected.

Those persistent failings continued until as late as 2019, and multiple opportunities to address them were ignored, including by the trust board accountable for these services. Reviews from external bodies failed to identify the substandard care that was taking place, and some of the findings gave false reassurances about maternity services at the trust. The Care Quality Commission rated maternity services inadequate for safety only in 2018, which is unacceptable given the huge deficiencies in care that are outlined in the report.

The report also highlights serious issues with the culture in the trust. For instance, two thirds of staff who were surveyed reported that they had witnessed cases of bullying, and some staff members withdrew their co-operation on the report within weeks of publication. The first report has already concluded that

“there was a culture within the Trust to keep Caesarean rates low because this was perceived as the essence of good maternity care”.

Today’s report adds:

“many women thought any deviation from normality meant a Caesarean section was needed and this was then denied to them by the Trust”.

It is right that both the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives have said recently that they regret their campaign for so-called normal births. It is vital, across maternity services, that we focus on safe and personalised care, in which the voice of the mother is heard throughout.

The report shows a systemic failure to listen to the families affected, many of whom had been doggedly and persistently raising issues over several years. One mother said that she felt like a

“lone voice in the wind”.

Bereaved families told the report that they were treated in a way that lacked sensitivity and empathy. Appallingly, in some cases, the trust blamed the mothers for the trauma that they had been through. In the words of Donna Ockenden, the trust

“failed to investigate, failed to learn and failed to improve”.

We entrust the NHS with our care, often when we are at our most vulnerable. In return, we expect the highest standards. I have seen in my family the brilliant care that NHS maternity services can offer, but when those standards are not met, we must act firmly, and the failures of care and compassion set out in the report have absolutely no place in the NHS.

To all the families who have suffered so greatly: I am sorry. The report clearly shows that you were failed by a service that was there to help you and your loved ones to bring life into this world. We will make the changes that the report says are needed, at both a local and national level.

I know that hon. Members and the families who have suffered would want reassurances that the individuals who are responsible for these serious and repeated failures will be held to account. I am sure that the House will understand that it is not appropriate for me to name individuals at this stage. However, I reassure hon. Members that a number of people who were working at the trust at the time of the incidents have been suspended or struck off from their professional register, and members of senior management have been removed from their posts. There is also an active police investigation, Operation Lincoln, which is looking at around 600 cases. Given that this is a live investigation, I am sure that hon. Members will recognise that I am not able to comment further on that.

Today’s report recognises that since the initial report was published in 2020, we have taken important steps to improve maternity care. That includes providing £95 million for maternity services across England to boost the maternity workforce and to fund programmes for training, development and leadership. The second report makes a series of further recommendations. It contains 66 for the local trust, 15 for the wider NHS and three for me as Secretary of State. The local trust, NHS England and the Department of Health and Social Care will accept all 84 recommendations.

Earlier today, I spoke to the chief executive of the trust, who was not in post during the period examined in the report. I made it clear how seriously I take this report and the failures that were uncovered, and I reinforced the message that the recommendations must be acted on promptly, but as the report identifies, there are also wider lessons that must be learned, and it sets out a series of actions that should be considered by all trusts that provide maternity services. I have asked NHS England to write to all of those trusts, instructing them to assess themselves against these actions, and NHS England will set out a renewed delivery plan that reflects those recommendations.

I am also taking forward the specific recommendations that Donna Ockenden has asked me to. The first is on the need to further expand the maternity workforce. Just a few days ago, the NHS announced a £127 million funding boost for maternity services across England. That will bolster the maternity workforce even further, and fund programmes to strengthen leadership, retention and capital for neonatal maternity care.

Secondly, we will take forward the recommendation to create a working group, independent of the maternity transformation programme, with joint leadership from the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists.

Finally, Donna Ockenden said that she endorses the proposals that I announced in January to create a special health authority to continue the maternity investigation programme that is run by the Healthcare Safety Investigation Branch. Again, we will take her proposals forward, and the SHA will start its work from April next year.

I thank Donna Ockenden and her whole team for the forensic and compassionate approach that she has taken throughout this distressing inquiry. The report has given a voice at last to those families who were ignored and so grievously wronged, and it provides a valuable blueprint for safe maternity care in this country for years to come.

Finally, I pay tribute to the families whose tireless advocacy was instrumental to the review being set up in the first place. I cannot imagine how difficult it must have been for them to come forward and tell their stories, and the report is a testament to the courage and fortitude that they have shown in the most harrowing of circumstances.

This report is a devastating account of bedrooms that are empty, families that are bereft and loved ones taken before their time. We will act swiftly, so that no families have to go through the same pain in the future. I commend this statement to the House.

[Mr Speaker]

The Secretary of State is quite right that this is a very important statement, so I will offer the shadow Minister, Feryal Clark, six minutes.

--- Later in debate ---

[Sajid Javid]

I thank the hon. Lady for her remarks. It is not often that we get to say this in this Chamber, but I agree wholeheartedly with what she has just shared with the House. She is absolutely right to talk about this as a fight for justice and to say that if these brave families had not been so persistent in coming forward with what was done to them and what went wrong, the inquiry might never have happened. She is also right to talk about institutional failure at the trust, which the first report set out in some detail and which we are seeing in much more detail today.

The hon. Lady talked, rightly, about patient safety. She will know that the Government have already set out plans to appoint a patient safety commissioner; that appointment will be made soon, but we need to do much, much more. That is why it was right to accept all the interim report’s recommendations, including seven immediate and essential actions and 27 local actions. I can tell the House that the trust has implemented all the actions set out in the interim report; that was backed at the time by £95 million in extra funding. As I said a moment ago, the final report quite rightly makes many more recommendations, which have all been accepted and which are backed by funding of at least £127 million, much of which will go to workforce.

The hon. Lady is right about the need to increase the size of the workforce, especially with respect to midwives. Last year’s acceptance figures for student nurses and midwives were, I think, the highest that the country had seen in decades, but clearly there is much more to do.

[Mr Speaker]

We now come to the Chair of the Health and Social Care Committee.

[Jeremy Hunt (South West Surrey) (Con)]

Today’s report goes beyond my darkest fears. When I commissioned it as Health Secretary in 2016, I was approached by 23 families; we have heard today that more than 200 babies might have been alive today if better care had been provided. I thank Donna Ockenden and her team for an incredibly thorough investigation. I also thank the Health Secretary for his compassionate and comprehensive response to the House today.

Donna Ockenden does not use the word “recommendation”; she talks about immediate and essential actions. What is the Secretary of State’s deadline for the implementation of those actions? That is something that every expectant mother in the country desperately wants to know.

May I gently say to the Secretary of State that while I warmly welcome more midwives and more doctors, that approach is not consistent with voting down today the Lords amendment to the Health and Care Bill that would make sure that we never have those shortages again?

Finally, I pay tribute to Richard Stanton and Rhiannon Davies and to Kayleigh and Colin Griffiths. Richard and Rhiannon came to talk to me about their daughter Kate, who died in 2009; Colin and Kayleigh’s daughter Pippa died in 2016, when I was Health Secretary. Because of the blame culture and the culture of fear in the NHS, it was left to them and many other families to fight for justice. Can this be the last time that we put that burden on the shoulders of bereaved families? Can we build a culture in the NHS that is open and transparent and that accepts that things go wrong, but is hungry to learn from mistakes so that we never again repeat the tragedies?