Baby Loss and Safe Staffing in Maternity Care

Patricia Gibson Excerpts

Tuesday 25th October 2022 Westminster Hall

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

I am pleased to participate this year in what has become a tradition of debating baby loss. I thank the hon. Member for Hartlepool (Jill Mortimer) for opening the debate; I participate as someone who suffered a stillbirth at full term and who almost died in the process.

Over the last year or so, I have gone to more funerals than I have in the rest of my 54 years of life so far. When we gather to bury our dead at funerals, we talk about them: we talk about what they were like, their foibles and their character, using anecdotes told with affection and laughter. They are mourned and remembered for the person they were. But with stillbirth, there are no such stories. Over time, you simply learn to live with a loss that changes you forever. At the funeral, all there is is a life unlived. There are no amusing anecdotes, there are no character foibles to remember, and there is no personality yet formed upon which to base memories. There is only the madness of grief for a life whose promise and potential have been unfilled and unrealised—a much longed-for and much wanted child, born fully grown and often otherwise perfectly healthy, dead before it can take its first breath. “Born sleeping” is so apt because such babies look exactly like that—a perfectly fully grown, normal baby, but one who is just so unnaturally quiet, appearing fast asleep, with a room all ready at home, prepared and waiting for their arrival. Your very stake in your future is gone.

I want to talk about pre-eclampsia, because it is the cause of so many stillbirths every year. To make an impact on stillbirths, we really need to learn and understand more about this condition. Its most deadly form is HELLP—haemolysis, elevated liver enzymes and low platelets—syndrome. What is interesting is that pre-eclampsia is associated with very serious long-term health risks for women who develop it during pregnancy. They are at long-term risk of chronic hypertension, ischaemic heart disease, cerebrovascular disease, kidney disease, diabetes mellitus, thromboembolism, hypothyroidism and even impaired memory. Who is monitoring the long-term health of women who have suffered pre-eclampsia? Why are the longer-term risks not specifically monitored? Women in those risk categories are not even told that they face those risks and they are simply unaware of the long-term health challenges they may face once they are discharged from hospital. How can that be right?

People talk, quite rightly, about stillbirths being a product of health inequality, but we also know that too often they happen as a result of systematic errors in care. Sometimes, the most basic red flags are simply overlooked, or at worst, ignored. We only have to see the recent, and frankly horrific, independent reports—the latest of which came out only last week regarding maternity care in East Kent, Nottingham, Shrewsbury, Telford and, to my deep regret, the Greater Glasgow and Clyde health board. In my experience, far from seeking to review procedures and learn lessons, that board simply lawyered up to seek to intimate me—and who knows how many other bereaved parents—into silence. It failed to silence me, but I have absolutely no reason whatever to believe that it has learned anything from the systematic errors that led to the death of an otherwise perfectly healthy, 8 lb 5 oz baby. Staffing was not the issue; it was systematic failures, negligence and incompetence that killed my baby and almost killed me.

In all these cases—some publicised recently—bereaved parents all say they encounter the same thing: cover-ups, ranks closing and few, if any, answers—only the isolation and bewilderment of emptiness. I have no confidence that this situation will change, which is why independent reviews are necessary. Health boards and health trusts seem simply unable or unwilling to admit errors without being forced to do so, and that is unacceptable and inexcusable. Despite the warm words, I have seen no evidence that that situation will change.

The bereavement care pathway, which many have mentioned today, is a very positive thing. If parents are to be listened to, their questions must be answered without fear of serious mistakes being uncovered. If there are serious mistakes to be found, they should be found; all else is cosmetic and, quite frankly, patronisingly pointless.

We have made some progress since the first debate I secured about stillbirth in 2016. There is now much greater willingness to talk about the babies whose lives are snuffed out before they can begin. The more that bereaved parents feel able to talk about stillbirth, the less isolated they will feel, but the isolation is real and debilitating, and its impacts are long lasting.

This year’s Baby Loss Awareness Week theme was stepping stones—depicting the path that people must take after losing a baby and the various stages of that journey. The fact is that, for those of us who have to carry out the grotesquely unnatural act of burying a fully grown baby, the path of grief does not end. Grief stays with you for the rest of your life; you simply somehow find a way to live with it.

It really is time that we stopped hearing about serious failings in maternity care that lead to stillbirths. How many times have we had reports? How many times have we had reviews? How many times have we had investigations? What health trust or health board does not know in this day and age what is required to deliver babies safely and support mums through their pregnancy?

Sadly, we know that the latest failures found in East Kent will not be the last. I honestly despair, and I know that all those who have been through a stillbirth also continue to despair, each time we hear of yet more systematic failures. Of course staffing is an issue, but it is not the whole story. For those babies already gone, it is too late, but Governments across the UK must do more to do better; otherwise, more babies will be born asleep.