Baby Loss Awareness Week

Patricia Gibson Excerpts

Thursday 19th October 2023 Commons Chamber

[Tim Loughton]

My hon. Friend, who again has great experience and has been exceedingly forward with her own experiences, is absolutely right. There have been many studies on maternal perinatal mental health problems. The latest estimate is that that costs this country over £8 billion, and there has been an increase in perinatal mental health problems among women, exacerbated by the lockdown.

As happened to our own colleagues, for many months babies born during lockdown did not come into contact with another baby, or with extended family members such as grandparents, who would usually be at the hospital bedside to welcome a new baby, but were not allowed to be there. Speaking as the chairman of the all-party parliamentary group for conception to age two: first 1001 days, we are only starting to see the considerable impact of that on babies. We will only start to see that as those babies grow up and go to school.

However, there have not been as many studies about the impact on the mental health of fathers. There is good evidence to suggest that fathers can suffer considerably, yet the support networks, which are still not good enough for mums, are not nearly good enough for fathers. It is a false economy not to support that.

In a minute, I want to have another rant about my Act, the Civil Partnerships, Marriages and Deaths (Registration etc) Act 2019—that is the real reason for my coming to this debate, although I always try to take part, because the Act deals with stillbirth, in particular—but first I will make some general comments.

It is good that we are discussing this issue and that the profile is so much higher than it has been in previous years, but there is a lot of work still to do. The stillbirth rates have come down and there has been progress. Back in 1993, there were 5.7 stillbirths per 1,000 births. There were 2,866 stillbirths in 2021, so the figure is now about 3.8 or 3.9 stillbirths per 1,000 births. There has been progress, but in order to get to the target under the national maternity safety ambitions, which was launched in 2015, we need to get that figure down to about 2.6 by 2025, so there is a lot of work still to do on stillbirths.

Compared with other European countries, our record on stillbirth remains poor. We rate sixth worst out the 28 European Union countries plus the UK. The countries below us are Bulgaria, Malta, Croatia, Slovakia and Romania, which have perhaps traditionally not had as advanced and sophisticated health services as we have in this country. There is no real excuse why we have not made more progress.

[Patricia Gibson (North Ayrshire and Arran) (SNP)]

The hon. Gentleman is correct in what he is saying. Does he agree that one of the problems across the UK is that, on the whole, most of the stillbirths we have are preventable? When mistakes occur, as they inevitably will at times, there is a culture of cover-up and secrecy, so the lessons that need to be learned are not being learned, because NHS trusts and health boards are too busy trying to cover their backs rather than finding out what went wrong.

[Tim Loughton]

The hon. Lady gallops way ahead of me; I will come on to speak about that. That is what my private Member’s Bill, now an Act, seeks to address, so I will come back to those comments.

Stillbirths are not the only issue. Progress has been poor on neonatal death rates, which have plateaued for some years and are even further away from coming down to those 2025 targets. There were 1,719 neonatal deaths last year—that is deaths within 28 days of being born. There is also the whole subject of miscarriage. I will not go into great detail on that, but we know that at least one in five pregnancies end in miscarriage, and there are probably more that we do not know about. The Government have done a lot of good work on this. I pay tribute to the former Health and Social Care Secretary, now Chancellor of the Exchequer, for his emphasis on safety in hospitals, particularly safety around maternity, and for the launch of the Safer Care Maternity action plan back in 2016, which were all about improvements in maternity safety training. The Our Chance campaign was targeted at pregnant women and their families to raise awareness of symptoms that can lead to stillbirth.

The inauguration of bereavement suites in hospitals was another important development—I have seen my own in Worthing. It was wholly unsatisfactory that a woman, following a stillbirth, would be placed in a bed next to a mother who had fortunately had a healthy, screaming baby. The impact on the mother and the father of having a stillbirth and then seeing the reverse was traumatic and had to be dealt with. The bereavement suites provided a more discreet, private area, away from those mums lucky enough to have healthy babies.

--- Later in debate ---

[Patricia Gibson (North Ayrshire and Arran) (SNP)]

I thank the hon. Member for North Shropshire (Helen Morgan) for bringing forward this debate, which has become something of an annual event in the calendar. It is very important that we have it.

I want to let the hon. Member for East Worthing and Shoreham (Tim Loughton) know that I agree with everything he said. In terms of coroner inquiries for stillbirths at full term, in Scotland we have fatal accident inquiries. Although it is devolved, it was one of the calls I made when I secured the first ever debate on stillbirth in this place in 2016. There is still a job of work to do to get us to where we want to be in that regard.

I always want to participate in this debate every year because I think it is an important moment—a very difficult moment, but an important one—in the parliamentary calendar. It is significant that the theme this year is the implementation of the findings of the Ockenden report in Britain, because that report was very important. We all remember concerns raised in the past about neonatal services in East Kent and Morecambe Bay, and the focus today on the work undertaken by Donna Ockenden in her maternity review into the care provided by Shrewsbury and Telford Hospital NHS Trust really matters.

Donna Ockenden is currently conducting an investigation into maternity services at Nottingham University Hospitals NHS Trust. That comes in the wake of the fact that in the past, concerns have been raised about a further 21 NHS trusts in England with a mortality rate that is over 10% more than the average for that type of organisation, with higher than expected rates of stillbirth and neonatal death.

To be clear, I do not for one minute suggest that this is not a UK-wide problem, as I know to my personal cost. As the Minister will know, concerns remain that, despite a reduction in stillbirths across the UK, their number is still too high compared with many similar European countries, and there remain significant variations across the UK. Those variations are a concern. We know that they could be, and probably are, exacerbated by the socioeconomic wellbeing of communities. We know that inequality is linked to higher stillbirth rates and poorer outcomes for babies. Of course, the quality of local services is also a huge factor, and this must continue to command our attention.

When the Ockenden report was published earlier this year, it catalogued mistakes and failings compounded by cover-ups. At that time, I remember listening to parents on the news and hearing about what they had been through—the stillbirths they had borne, the destruction it had caused to their lives, the debilitating grief, the lack of answers and the dismissive attitude of those they had trusted to deliver their baby safely after the event. I do not want to again rehearse the nightmare experience I had of stillbirth, but when that report hit the media, every single word that those parents said brought it back to me. I had exactly the same experience when my son, baby Kenneth, was stillborn on 15 October 2009—ironically, Baby Loss Awareness Day.

That stillbirth happened for the same reasons that the parents described in the wake of the Ockenden report. Why are we still repeating the same mistakes again and again? I have a theory about that, which I will move on to in a moment. It was entirely down to poor care and failings and the dismissive attitude I experienced when I presented in clear distress and pain at my due date, suffering from a very extreme form of pre-eclampsia called HELLP syndrome. I remember all of it—particularly when I hear other parents speaking of very similar stories—as though it were yesterday, even though it is now 14 years later. I heard parents describing the same things that happened to me, and I am in despair that this continues to be the case. I hope it is not the case, but I fear that I will hear this again from other parents, because it is not improving. I alluded to that in my intervention on the hon. Member for East Worthing and Shoreham, and I will come back to it.

While I am on the issue of maternal health, expectant mothers are not being told that when they develop pre-eclampsia, which is often linked to stillbirths, that means they are automatically at greater risk of heart attacks and strokes. Nobody is telling them that they are exposed to this risk. I did not find out until about five years after I came out of hospital. Where is the support? Where is the long-term monitoring of these women? This is another issue I have started raising every year in the baby loss awareness debate. We are talking about maternal care. We should be talking about long-term maternal care and monitoring the health of women who develop pre-eclampsia.

[Steven Bonnar (Coatbridge, Chryston and Bellshill) (SNP)]

My hon. Friend is making a very personal speech, and I am sure we are all listening intently. Will she join me in paying tribute to the wonderful charity that serves my constituency, Baby Loss Retreat, based in Glasgow? It is helping people through the most traumatic of times and making a real difference to families. Will she join me and that charity in calling on this place and the Government here to make available a register for certification for babies who are lost within 24 weeks of pregnancy? That has already been implemented by the Scottish Government, and it means so much to families who are coming to terms with such loss at a tragic time.

[Patricia Gibson]

I thank my hon. Friend for his intervention. I can see that the Minister was listening carefully, and I am sure she will want to take that back to her colleagues in Cabinet who can take the action that would allow parents who want a certificate before 24 weeks to have one. I also share his view about the importance of the charitable work that is done to support not only mums and dads but grannies and grandfathers when a stillbirth happens, providing them with the local, sensitive support that they need, because it is not always forthcoming from the NHS. When people try to regroup after this kind of loss, that ongoing support in the community is really important.

We are seeing too many maternity failings, and now deep concerns are being raised about Nottingham University Hospitals NHS Trust. I understand that the trust faces a criminal investigation into its maternity failings, so I will not say any more about it. The problem is that when failures happen—and this, for me, is the nub of the matter—as they did in my case at the Southern General in Glasgow, now renamed the Queen Elizabeth University Hospital, lessons continue to be not just unlearned but actively shunned. I feel confident that I am speaking on behalf of so many parents who have gone through similar things when I say that there is active hostility towards questions raised about why the baby died. In my case, I was dismissed, then upon discharge attempts were made to ignore me. Then I was blamed; it was my fault, apparently, because I had missed the viewing of a video about a baby being born—so, obviously, it was my fault that my baby died.

It was then suggested that I had gone mad and what I said could not be relied upon because my memory was not clear. To be absolutely clear, I had not gone mad. I could not afford that luxury, because I was forced to recover and find out what happened to my son. I have witnessed so many other parents being put in that position. It is true that the mother is not always conscious after a stillbirth. Certainly in my case, there was a whole range of medical staff at all levels gathered around me, scratching their heads while my liver ruptured and I almost died alongside my baby. Indeed, my husband was told to say his goodbyes to me, because I was not expected to live. This level of denial, this evasion, this complete inability to admit and recognise that serious mistakes had been made that directly led to the death of my son and almost cost my own life—I know that is the case, because I had to commission two independent reports when nobody in the NHS would help me—is not unusual. That is the problem. That kind of evasion and tactics are straight out of the NHS playbook wherever it happens in the UK, and it is truly awful.

I understand that health boards and health trusts want to cover their backs when things go wrong, but if that is the primary focus—sadly, it appears to be—where is the learning? Perhaps that is why the stillbirth of so many babies could be prevented. If mistakes cannot be admitted when they are made, how can anyone learn from them? I have heard people say in this Chamber today that we do not want to play a blame game. Nobody wants to play a blame game, but everybody is entitled to accountability, and that is what is lacking. We should not need independent reviews. Health boards should be able to look at their practices and procedures, and themselves admit what went wrong. It should not require a third party. Mothers deserve better, fathers deserve better, and our babies certainly deserve better.

Every time I hear of a maternity provision scandal that has led to stillbirths—sadly, I hear it too often—my heart breaks all over again. I know exactly what those parents are facing, continue to face, and must live with for the rest of their lives—a baby stillborn, a much-longed-for child lost, whose stillbirth was entirely preventable.

[Cherilyn Mackrory]

I am really grateful to the hon. Lady for the testimony she is giving, and I absolutely agree with almost everything she is saying. However, does she agree that there is a very big difference between a genuine mistake that a midwife or health professional might make and negligence, and does she think we need to get better at differentiating those two things, so that healthcare professionals are not afraid to come forward and give the right information when an investigation takes place?

[Patricia Gibson]

I absolutely agree with the hon. Lady. The frustration, and the piling of trauma on tragedy, comes from the inability to engage at any level when things go wrong. Everybody knows that things can go wrong. People are human and they will make mistakes. It is what happens afterwards that matters. That is what matters to bereaved parents.

Some people talk about workforce pressure, and it has been mentioned today. However, to go back to the point made by the hon. Member for Truro and Falmouth (Cherilyn Mackrory), for me and, I think, many of the parents who have gone through this, the fundamental problem is the wilful refusal to admit when mistakes have happened and to identify what lessons can be learned in order to prevent something similar happening again. To seek to evade responsibility, to make parents feel that the stillbirth of their child is somehow their own fault or, even worse, that everyone should just move on and get on with their lives after the event because these things happen—that is how I was treated, and I know from the testimony I have heard from other parents that that is how parents are often treated—compounds grief that already threatens to overwhelm those affected by such a tragedy. I do not want to hear of another health board or NHS trust that has been found following an independent investigation to have failed parents and babies promising to learn lessons. Those are just words.

When expectant mums present at hospitals, they should be listened to, not made to feel that they are in the way or do not matter. How hospitals engage with parents during pregnancy and after tragedy really matters. I have been banging on about this since I secured my first debate about stillbirth in 2016, and I will not stop banging on about it. I am fearful that things will never truly change in the way that they need to, and that simply piles agony on top of tragedy. I thank Donna Ockenden for her important work, and I know she will continue to be assiduous in these matters in relation to other work that she is currently undertaking, but the health boards and health trusts need to be much more transparent and open with parents when mistakes happen. For all the recommendations of the Ockenden report—there are many, and they are all important—we will continue to see preventable stillbirths unless the culture of cover-ups is ended. When the tragedy of stillbirth strikes, parents need to know why it happened and how it can be prevented from happening again. That is all; a baby cannot be brought back to life, but parents can be given those kinds of reassurances and answers. That is really important to moving on and looking to some kind of future.

It upsets me to say this, but I have absolutely no confidence that lessons were learned in my case, and I know that many parents feel exactly the same. However, I am very pleased to participate again in this annual debate, because these things need to be said, and they need to keep being said until health boards and NHS trusts stop covering up mistakes and have honest conversations when tragedies happen, as sometimes they will. Parents who are bereaved do not want to litigate; they want answers. It is time that NHS trusts and health boards were big enough, smart enough and sensitive enough to understand that. Until mistakes stop being covered up, babies will continue to die, because failures that lead to tragedies will not be remedied or addressed. That is the true scandal of stillbirth, and it is one of the many reasons why Baby Loss Awareness Week is so very important, to shine a light on these awful, preventable deaths for which no one seems to want to be held accountable.

[Madam Deputy Speaker (Dame Eleanor Laing)]

I call the shadow Minister.