Baby Loss Awareness Week

Steven Bonnar Excerpts

Thursday 19th October 2023 Commons Chamber

[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.