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Showing every spoken contribution, including 12,868 under 12 words. Hide short remarks
The Minister may well know that it was only a few years ago that the UK met 40% of its own nitrogen and fertiliser needs. Would he commit to working with the Minister for Industry to look at how we can get our domestic production to grow once again, given that under the Conservative party it disappeared altogether?
I put on record my thanks and respect for the resolute campaigning of the Nottingham survivors, especially my constituents, Jack and Sarah Hawkins, who have worked so hard to bring these issues to regional and then national attention. They have made sure that baby Harriet’s death was not in vain. I also pay tribute to my hon. Friend the Member for Nottingham South (Lilian Greenwood) who was their MP for many years. As she is a Minister, she will not be speaking in this statement, but she deserves recognition for the steadfast support she gave to them as a family, as well as other families from Nottingham South. I thank Donna Ockenden who, in addition to supporting thousands of families, invested so much time in Nottingham and Nottinghamshire MPs to ensure that we understood the systemic failings that she was working so hard to identify. This is undoubtedly a shameful day for the NHS. Another fearless campaigner from Rushcliffe is Ashley Harper, who has been in touch with me about the maternity and neonatal taskforce and its perceived failure to recognise and support families who have been harmed. She would like to see a family expert for harmed children and a family expert for harmed mothers on the taskforce. I know that these asks have been raised by my brave and hon. Friend the Member for Sherwood Forest (Michelle Welsh), who has done so much for the Nottingham families, but will the Secretary of State say whether that is something he is actively considering?
With permission, Madam Deputy Speaker, I will make a statement on the independent review of maternity services at Nottingham University hospitals NHS trust. Donna Ockenden’s review is the largest into a maternity service in the history of the NHS. The nature and sheer scale of the failings it exposes are horrific. It uncovers dangerously and tragically deficient care at almost every turn. Its findings and conclusions are chilling. The report covers 13 years, including accounts from 838 members of staff and, crucially, the experiences of 2,536 affected families. I met a small number of those affected families last week, and I felt numb after hearing the depth of their pain. I felt even more numb when I considered how many families not in the room went through such trauma too, and the forgotten children who survived but live every day with the consequences of maternity care failings. I felt devastated that so many women and babies, as well as their fathers and other family members, had suffered injury, death and lasting trauma while under the care of the NHS. Now having met the families, and having seen the report, I feel appalled by the neglect, incompetence, racism, discrimination, contempt and harassment that so many suffered. I feel heartbroken to know that, so many times, when they tried to raise the alarm about their care, they were ignored, sneered at, disbelieved, blamed and lied to. How on earth could this have happened? There is no single answer, but Donna Ockenden shines a light on what was going on. First and foremost, women were not listened to. Donna Ockenden says that the staff shortages and lack of training in Nottingham were among the worst she has ever come across. Bullying by doctors and senior midwives was rife, which meant that staff who tried to speak up were intimidated and ridiculed. There was a culture of cover-up at the highest levels of the trust, and there were ineffective and inadequate responses from regulators. Perhaps most damning of all, for years the trust ignored evidence of clinical and cultural flaws in both internal and external reviews that it had itself ordered. When I met Donna Ockenden last week, she told me that those inquiries were “diligent” and of “good quality” but that they were effectively swept under the carpet by the board. That refusal to act is unforgivable. Donna Ockenden and her team deserve huge credit for their forensic and compassionate approach, as does my hon. Friend the Member for Sherwood Forest (Michelle Welsh), herself a harmed mother, as well as Members for neighbouring constituencies who have walked side by side with their constituents through years of anguish and struggle. However, the driving force behind the review has been the affected families themselves. They have demonstrated more patience, more courage and more tenacity than one might imagine is possible from those dealing with broken hearts that will never mend. Though each of their experiences is unique, one feature is common: at the very moment when they were at their most vulnerable, they placed themselves and the lives of their unborn babies in the hands of the NHS—and the NHS failed them catastrophically. To all those who have suffered so appallingly, I say today, on behalf of the NHS: I am sorry. I am sorry not just for the failures, or the heartless and undignified treatment, but because your cries of concern went unheard for too long—and so the Government will act. We will act by taking immediate steps, including to expand Martha’s rule to all maternity and neonatal settings so that parents can demand a second opinion if they feel their concerns are being ignored. I know that some people may want me to accept all the review’s recommendations today, but in the past too many recommendations have been accepted and then have sat on a shelf gathering dust, and we have seen more deaths and more suffering. I do not want to let down the families I met in Nottingham, or bereaved parents anywhere else in the country. I want to use the national maternity and neonatal taskforce, which I chair, to create a comprehensive action plan to be published by the end of this year that will address all the national-level recommendations from this review and others. I am confident that work will be welcomed by all those midwives, obstetricians, paediatricians and other healthcare workers who strive every day to make sure that babies are born safely and that women receive outstanding levels of care. It is clear that, in case after case, families felt that regulators, including the General Medical Council, the Nursing and Midwifery Council and the Care Quality Commission, were more concerned with protecting clinicians than with providing accountability. That is damning and that is wrong. As one grieving mother told me: “They put the fox in charge of the hen house.” Clinicians and trust leaders must know that their behaviour will be properly scrutinised and that their actions will have consequences. We must meet the test of the Nottingham victim who told me last week that “accountability drives action”. We are making changes to the CQC, one of which is to extend the cut-off period to initiate proceedings from three to five years so there is more time for families to bring cases. I will also call in the chair and chief executive of the GMC to hear directly their account of the failures at NUH. Let me be clear: if their response falls short, things will change at the GMC. From speaking to families in Nottingham, I know that there is real and understandable anger that some leaders and clinicians at the centre of this review were able to avoid giving evidence. Today, I make a commitment that, when passed, we will use the Hillsborough law’s duty of candour to ensure that witnesses in upcoming reviews of maternity service failures, including those in Leeds and Sussex, can be forced to provide evidence. That change will make sure no one is able to refuse to co-operate in the search for accountability and justice ever again. There is so much in the stories of the families in Nottingham that is shocking and heartbreaking, but the way the bodies of their loved ones were handled by hospital mortuary services revealed a level of disrespect and a lack of humanity that—I will be honest—left me utterly aghast. The details are disturbing, but they need to be heard to understand the gravity of what families were confronted with: deceased babies referred to as a “specimen” or “sample”; a baby placed into a mortuary space already occupied by an unknown and unrelated adult; a baby disposed of as clinical waste against the express wishes of their parents; and a baby kept in a domestic fridge in a bereavement room. The emotional and psychological effect of those dehumanising failures was to layer the most profound disrespect on the most unbearable distress. There is also evidence that the trust actively decided not to report failings in mortuary care to families. As hon. Members will know, there is an active police investigation and arrests have been made, which limits what I can say. As a start, however, I have asked NHS England to write to trusts to make sure these appalling experiences are not happening elsewhere in the NHS. I confirm today that the Human Tissue Authority will require all mortuaries to review internal records going back 10 years to ensure all incidents have been logged and reported. I have instructed them to report the findings directly to me by 16 October. When I met the Nottingham families last week, they also raised with me the issue around what are known as secondary victims. In maternity settings, fathers, partners and others are actively encouraged to be present to support mothers through labour and delivery. However, the law does not allow them to bring their own claims for the psychiatric illness suffered as a direct result of witnessing their partner or baby suffer injury or die. I have therefore asked David Lock KC to work with my officials to consider that important issue as part of his wider work on clinical negligence. Donna Ockenden acknowledges that NUH has not waited for her findings to be published to start making improvements. I will speak to the chief executive next week to interrogate the trust’s response and make sure there is a proper plan in place for implementing the recommendations speedily and effectively. But there is a long road ahead before NUH fully addresses all the issues and before it can possibly regain the full trust and confidence of the communities it serves. I close where I began: with the families. Nothing can make up for what they have gone through, but this report is a tribute to their resilience and tenacity. I say to them directly: you had to drive this for so long, but you are no longer driving this alone. We are with you and we will not stop until you have the accountability and the justice you deserve. I commend this statement to the House.
I thank the shadow Secretary of State for not only the content but the tone of his response, and for the approach that he has taken. I firmly welcome this collaborative approach, because he rightly points out that this is an area that we should work across parties and across this whole House to address. His summary of the key issues that we must address through the work that we are doing—first and foremost, ensuring that women are listened to; the cultural changes we need to see; and the delivery test, recognising that this is a chain of failure—was very well made and in line with where I and the Department are coming at this issue from. As I mentioned earlier, all the recommendations from today’s report, as well as the recommendations from the national report that Baroness Amos has been working on and from other inquiries and reviews of maternity service failures, will come to the national taskforce that I chair, precisely to deliver that delivery plan—that comprehensive plan of action. We will ensure that it is published by the end of this year, and the Government, working with the Opposition, will ensure that it is delivered across this country.
I thank my hon. Friend for her questions. Let me put on record again how much I have appreciated her advocacy, her support, her sharing of her own experience and her standing up for the many hundreds of families in the area she represents. Her contribution is invaluable to this most important work that we are doing as a Government. She talked about families driving this report and making sure that it happened, and she is absolutely right. I met some of those families last week in Nottingham, and as well as feeling numb at the depth and breadth of their pain, the feeling I left with was a sense of their exhaustion at having fought for so long to be listened to and to get this into the open. Our responsibility as a Government and as MPs is to say that, now it is out in the open for us all to see, we all bear a responsibility to help them carry this forward. I take that responsibility with the utmost seriousness. My hon. Friend asked about a plan to change maternity services in Nottingham and across the country. There will be specific local recommendations in Nottingham, and I am meeting the chief executive of the trust next week to pick that up directly with him, but there are more recommendations in the report that will have national implications, along with the recommendations from the national review that is under way. It is crucial that all those recommendations are formed into a plan of action, and the taskforce that I chair will be crucial in making sure that these recommendations do not just get accepted and then sit on a shelf gathering dust, but form a plan of action that we can stand behind as a Government. Finally, my hon. Friend mentioned the importance of action, accountability and change. I repeat what I said in my statement: one of the phrases that stuck with me powerfully from my meeting with Nottingham families last week was from the person who said that “accountability drives action”. Without that accountability, we cannot have a guarantee of action. That is why the accountability that the families seek is the change that we as a Government must seek to deliver.
I thank the hon. Lady for her words. When she spoke about ending this cycle, she sums up a feeling that I think many of us have: the cycle of inquiries and investigations revealing what has been happening in maternity services and leading to recommendations, which are accepted, but then things do not change enough, and action is not taken to address all the issues raised. That is the cycle we need to break. The national taskforce, which is established and which I chair, will take all the recommendations from Donna Ockenden’s report, as well as those from Baroness Amos’s national review, which will be published shortly, as well as some of the other hundreds of recommendations that the hon. Lady mentioned, and ensure that it produces a comprehensive action plan by the end of the year. The challenge for us is not simply to accept recommendations, but to produce and deliver that action plan.
I thank my hon. Friend for his comments and questions, and I echo his words about paying tribute to the courage, dignity and determination of the families who have driven the report and driven these shocking failures out into the open, so that we can all see the scale and depth of what has happened. He asks me about embedding the lessons from the review. I assure him that my priority is to ensure that the local lessons around the situation in Nottingham are embedded, and I will meet the chief executive of the trust next week, but also that those recommendations that have implications about national maternity services are taken directly into the taskforce that I chair, along with recommendations from other reports, and that we produce that plan of action by the end of the year. Let me also reassure him that, in that search for change, justice and accountability, I will take nothing off the table.
I thank the hon. Lady for her comments. She speaks about funding, which is of course a very important part of the response that we need to have to the failings in maternity care. We are investing £25 million, as I am sure she is aware, in tackling the causes of maternal death, to enhance bereavement facilities and to improve triage facilities, as well as £145 million through the estates safety fund to address safety risks in the maternity and neonatal estate. For me, this is not just about funding; this is also about culture, exactly as she says. When there is a culture of mothers and midwives not being listened to, and of the board, in this case, commissioning reviews and then ignoring them, that is where the problem lies. That is what we need to change. There is no single lever we can pull, no single change we need to make; we need to ensure that, from top to bottom, maternity services are overhauled in order to be fit for the future.
I thank my hon. Friend for her comments and questions. As well as thanking the families for what they have done to drive the report forward, she also thanked Donna Ockenden for her critical work in producing this report, and to those thanks I add my own. My hon. Friend asks about the timetable for action. The national taskforce, which I chair, will draw together all the national recommendations, all the recommendations from Donna Ockenden’s report, the recommendations from Baroness Amos’s report, and any other report on failures in maternity services, and the taskforce will report by the end of the year. That will be the timetable for us ensuring that there is a comprehensive plan of action. I know from my conversations with families that some have wanted a public inquiry and others have had different views. Let me be clear that, for me, no options are off the table.
I sincerely thank the right hon. Gentleman for his comments. I have a great deal of respect for him, as he knows, so I very much appreciate him making his suggestions in that manner. Let me add to what he said about Jack and Sarah Hawkins, who I met last week in Nottingham. Their sheer determination to push for accountability and justice is incredibly humbling. The right hon. Gentleman mentions the importance of clinical accountability, which gets to the core of how to drive change in the NHS—as he knows, and as I now know, that is not always possible through central control, or by instructions being sent out from the Department of Health and Social Care or NHS England. We must ensure that the entire system is structured in the right way to provide that accountability and to drive change and action, and I will put under careful consideration his suggestion about how that might be achieved.
My hon. Friend raises the important issue of compelling witnesses to give evidence. Although many members of staff contributed towards Donna Ockenden’s review, I found the fact that so many senior leaders did not shocking, and I think it is unacceptable. We will change that by ensuring that the duty of candour, which is due to come in under the Hillsborough law once that is in place, will apply to future maternity reviews, including those taking place in Leeds and Sussex. As I said a few moments ago, there are different views among different families about whether they do or do not want a public inquiry, but I am not taking any options off the table.
I thank the right hon. Gentleman for his remarks. The story he told was of yet another horrific and harrowing experience that a family has gone through in this scandal. He asked whether we want to prioritise a focus on regular and high-quality training across the country, and I think it is essential to ensure that such training is in place. Although I do not want to prejudge the action plan that the taskforce I am chairing will produce, I cannot imagine a world where training is not a key part of that. Having seen the report, and spoken to families and to Donna Ockenden, my strong feeling is that no single action will transform the system on its own, and that we need a comprehensive plan from every angle to truly transform maternity services across the country.
I thank my hon. Friend for her comments and I welcome her support for our decision to ensure the duty of candour introduced by the Hillsborough law will apply to future maternity reviews, such as those due to happen in relation to Leeds and Sussex. In terms of the process of what happens next and the implementation of the changes that we know need to happen, I reassure her that the national taskforce that I chair will produce, by the end of this year, a comprehensive plan of action that will be based on a consideration of all the recommendations that apply nationally in Donna Ockenden’s review, as well as the recommendations from Baroness Amos’s review and any other reviews that have issued recommendations on the subject too.
I thank the right hon. Gentleman for his comments and for telling us some of the story of Thomas and his son, Aubrey. On the need for action, I intend the taskforce that I chair, which will consider all the recommendations from Donna Ockenden’s report and other investigations into failures in maternity services, to produce a comprehensive action plan by the end of this year. That will ensure, as I said earlier, that these recommendations do not sit on shelves gathering dust and that they are put into action. I take on board his points about a public inquiry. I know that his views are shared by some of the families, but I am conscious that other families have different views on this matter. What unites them all is a desire for action, accountability and justice. We need to find the best route to deliver that for them, because that is, above all, the most important thing. However, I reassure him, as I have reassured other hon. Members, that for me no options should be off the table.
I thank my hon. Friend for her comments about the role of the families in fighting for justice. She is absolutely right that the recommendations of the Ockenden report, Baroness Amos’s report, which is due shortly, and other reviews and inquiries into maternity services must not simply end up on the shelf gathering dust. That is why the process that I have spoken about today, whereby the national taskforce that I chair will produce a comprehensive action plan by the end of the year, is so important. That will give us the right forum to develop a plan across all aspects and from all angles on this horrific scandal, including the inequalities faced by different families from different backgrounds that my hon. Friend alluded to. I agree with her wholeheartedly that this moment and this process that we are now going into must be a catalyst for change.
The hon. Gentleman makes an important point about regulators and our regulatory system. The report exposes how completely unacceptable it is that regulators have protected their own and what a serious matter that is. We need to ensure that the regulators are doing their job properly, that they have the right mandate to do so and that they have the right instructions about driving up performance in trusts across the country, because otherwise we run the risk of being in a situation in the future where we are again confronted with what he accurately described as shame.
Let me repeat what I said earlier about my humble admiration for Jack and Sarah Hawkins and their campaign for justice over baby Harriet. My hon. Friend is absolutely right to refer to the failings as systemic. This is not a handful of cases or problems; this truly is a problem that affects the entire system. The culture and the systems that are in place have let people down, and that is why our response must be so comprehensive. My hon. Friend mentions the input of families into the taskforce and his constituent Ashley Harper, who raised that matter. I am very happy to discuss with him after this statement how we can ensure that the taskforce represents the views of all families.
The right hon. Gentleman raises an important part of the dynamic that has been exposed through Donna Ockenden’s review: people not feeling able to challenge what is happening—feeling that they are being intimidated or forced to stay silent—even when they want to raise issues of great importance. We must ensure that the right structures and culture are in place not only so that women and their families can raise their concerns, but so that staff, midwives and others working in maternity and neonatal services have the confidence to raise their concerns through whatever mechanism is most appropriate in the circumstances. They must have confidence in the mechanism to raise their concerns. The right hon. Gentleman spoke about clinicians who refused to take part in Donna Ockenden’s review in Nottingham. As I said earlier, although more than 800 members of staff contributed towards the review, I was appalled at the number of senior clinicians who did not agree to take part. That is why it is so important that we change the law—applying the duty of candour through the Hillsborough law to ensure that this can never happen again.
My hon. Friend asks about the immediate actions that the Government are taking in response to Donna Ockenden’s review. For me, above all else—above all the shocking, harrowing detail—the review highlights the fact that women simply were not listened to. That comes up time and again. I know that it comes up in other aspects of healthcare as well, but it came up so strongly in this report and underlined so many of the shocking failures that have occurred. As a first step, extending Martha’s rule to all maternity services across the country means that when women or their family members are concerned that they are not getting the treatment or care they need, they can get a second opinion—an urgent, independent review. That is an important first step, but this must be a watershed moment that does not rely simply on one action or a small handful of actions. There must be a comprehensive plan to tackle this issue from every angle and to ensure that we have the systemic change that so many Members today have said is crucial.
The hon. Lady makes an important point about the fatigue, weariness and exhaustion of families at so many recommendations being made and accepted but not put into action. To pick up on the point made earlier by the Liberal Democrat spokesperson, the hon. Member for North Shropshire (Helen Morgan), we must now break that cycle to ensure that the recommendations do not simply get accepted and sit on a shelf gathering dust, but that they feed into the plan of action, which will then produce the change that we need to see. As the hon. Member for Canterbury (Rosie Duffield) said, the change must be nationwide. Although we are today rightly talking about what happened in Nottingham, we know that it is far from the only place where such failures in maternity and neonatal services have been seen. We know this is a national problem that needs a national solution.
I thank my hon. Friend for her comments, and for talking about the shocking situation with her daughter’s baby that she managed to avert. She spoke about the inequalities, the racism and the fact of women being silenced, all of which come through very strongly in Donna Ockenden’s report. As I have explained, the taskforce I chair will now consider the full set of recommendations from that report, as well as the recommendations from Baroness Amos’s national review and other reviews and inquiries into what has happened in maternity services. That taskforce will produce a comprehensive plan of action that will cover the whole range of actions that need to be taken, because we know it will take more than one action, or even a small handful of actions, to transform maternity services and make them as they should be. This is a problem that goes very deep; it is systemic, cultural and deeply embedded, and a comprehensive plan will be required to change that.
I thank the hon. Gentleman for his remarks, and for his tone and approach in encouraging cross-party working—he is absolutely right that that will be essential for making progress on this most important issue. I will consider the important point he has made about the Ministry of Justice and its remit in relation to what we have seen in mortuary services. As I said earlier, in a report full of shocking revelations, that inhumanity and lack of dignity left me truly aghast; it is almost unbelievable that it could have happened. The hon. Gentleman also raises an important point about women and their families across the country using maternity services. While the conversation we are having today is of course about the failures in Nottingham, we know that most women will receive high-quality care, and the majority of the NHS workforce do an important job supporting them. We should make sure that is acknowledged in this difficult conversation. However, one of the changes we want to make immediately is extending Martha’s rule to maternity services right across the country, because we know it is something we can do now. Martha’s rule is a mechanism that has worked well in other parts of the NHS, and it will mean that when women and their families feel they are not being listened to, they will have a way to get an urgent, independent review of the care they are receiving.
I thank my hon. Friend for his question. I was personally inspired by meeting Ryan’s mum Sarah when I visited Nottingham last week—she told me about Ryan, and showed such incredible strength and courage in advocating for the forgotten children in Nottingham. I can reassure my hon. Friend and the whole House that I will do everything in my power to support children with acquired brain injuries. We are working on an acquired brain injury plan at the moment, and I am also working with the Department for Education and NHS England on ambitious reforms to the special educational needs and disabilities system, including on the future direction of EHCPs.
I thank the hon. Gentleman for drawing my attention to that report. We will certainly ensure that any reports containing relevant recommendations are considered as part of the taskforce’s work, because one of the changes that I want to make sure we achieve is to not have so many different reports with hundreds of recommendations that then do not become a plan of action. That is a cycle we are seeking to break through the taskforce’s work by producing a plan of action by the end of the year.
My hon. Friend is absolutely right to point to regulatory failure, which has been drawn out very strongly by Donna Ockenden’s report. For me, what is completely unacceptable is that in their response to what has happened in Nottingham, they have sought to protect their own. That is something we must change, because it is only through effective regulation that we can have true accountability, and it is only through true accountability that we can get action and change.
I thank the hon. Lady for welcoming our decision about applying the duty of candour to future maternity reviews and inquiries, including those in Sussex and Leeds. We have always been clear that the Public Office (Accountability) Bill—the Hillsborough law—is an important priority for this Government. As soon as it is in law, we will ensure that the duty of candour is applied. Our commitment today is to ensure that NHS staff, current or past, cannot refuse to take part in what the lead investigator wants in future inquiries.
I commend my hon. Friend on mentioning his constituent, Louise Thompson, who is campaigning on this important issue. He mentioned the impact of racism, discrimination and inequality in maternity services and their failures—all raised powerfully by Donna Ockenden’s report today. As I said earlier, the action plan, which the taskforce will be producing, will be published by the end of this year. We are determined to break that cycle where recommendations get accepted and then get left on the shelf to gather dust. We want an action plan that can be implemented. We want to make sure that delivery is set out and is progressed by the Secretary of State and the Department. That is a key part of the accountability in making sure that the delivery plan is put into action.
I thank the hon. Lady for expressing how she feels angry and upset. I think that that feeling is shared by all of us in the House today. The publication of Donna Ockenden’s report today has exposed the lifelong suffering of those families. The details of the action plan will be published by the end of the year, because we want to make sure that recommendations are not simply accepted and then not implemented. The recommendations must go into the taskforce, and the taskforce must produce that clear action plan, which we can then implement, and people can see us doing so. That is the way to break the cycle of recommendations that do not get implemented and to make progress towards the justice, accountability and change that I understand from families is so important to them.
I thank my hon. Friend for raising the important issues that she referred to in her remarks. I am happy to make sure that either me or a member of my ministerial team will meet her to discuss them in further detail.
My hon. Friend speaks about his constituents whose experience might be relevant to some of the findings around mortuary services and their failings. I would be happy to ensure a meeting with either me or a member of my ministerial team. As I said earlier, the details of what happened in mortuaries leave me struggling for words, because of how dehumanising, disrespectful and abhorrent that was. I would be happy to make sure that his constituents’ points are picked up as part of that. On learning the lessons from the review in Nottingham and applying that to Leeds and Sussex, we are fortunate that Donna Ockenden will be leading those reviews, having just completed the review in Nottingham. She will be in a strong position to ensure that she goes into that with the learnings she has made from the current review. One of those learnings that I am conscious of is how unacceptable it is that senior leaders refused to take part, for which I can see no justification whatever. I am pleased that, through the duty of candour that have we spoken about today, that will no longer be possible.
I thank my hon. Friend for his comments, and for telling us what happened to his constituent. He asked about some of the wider changes that we are making in the NHS modernisation Bill. The aim is to bring the patient experience across the NHS into the heart of the new organisation that will arise from the merging of NHS England into the Department of Health and Social Care to ensure that the patient experience drives the decisions being taken about how NHS care is delivered, and is at the heart of what we do as a Department and a national health service. However, as the report makes clear, the level of failure in maternity and neonatal services is truly devastating. It demands a specific response, which is why the work of the taskforce will begin and it will report by the end of the year. As my hon. Friend has said, this is not just a case of individual cases going wrong or individual members of staff making the wrong decision. It is endemic, and shows the incuriosity of leaders in maternity services about what is going on and what is going wrong in their services. It is a failure of regulators, it is systemic, and the response to it must step up accordingly.
My hon. Friend is right to emphasise quite how shocking it is that people in senior leadership positions refused to take part in Donna Ockenden’s review. I cannot understand how they could make that decision and think it acceptable. That is exactly why the law needs to change. It shows why the Hillsborough law is so important and why it was important to put it on the statute book, and also why it was important for us to decide now to apply that duty of candour to future reviews of the failures of maternity services so that never again can NHS staff, current or past, decide not to take part in the search for justice and accountability that it is so crucial for us to deliver.
I thank my hon. Friend for sharing with us his experience of brain injury in his own family, and for reminding us how some of the issues that we are discussing today touch the lives of many people in the House and across the country. We all have a responsibility to act on the basis of the recommendations of today’s report, and I assure my hon. Friend that those recommendations, along with those in Baroness Amos’s report, will enable the taskforce to produce a comprehensive action plan. A key element of that work—this concerns his direct point—will be ensuring that when people are at greater risk of harm, greater risk of being ignored, greater risk of being discriminated against, lied to or not being given the care that they need, that inequality will be addressed.
Although the report that we are discussing today deals with what has happened in Nottingham over the past 13 years, my hon. Friend is right to point out that it has not just happened in Nottingham and it has not just happened over the past 13 years. When I have spoken to people about this report, even today, so many have shared their own stories from many years ago in all different parts of the country. That reminds us that although the focus of the report is what has happened to the families in Nottingham, this issue affects families throughout the country, which is why, as my hon. Friend says, it is “all too familiar” to so many people when they hear what has happened. That is why it is so important that we develop our plan, which will have a nationwide impact, in order to finally tackle this challenge head-on and ensure that we deliver the maternity and neonatal services that women across the country need and deserve.
Q13. The Coal Industry Social Welfare Organisation, a miners’ charity established in the 1920s to support the miners in their communities, has carried out some incredible work with some incredible employees, but the current leadership team is increasingly detached from its founding principles. Miners’ welfare, sporting facilities and community facilities have been allowed to rot and to close with little to no support from CISWO. At the same time, CISWO has amassed £30 million in the bank. Does the Prime Minister agree that it is time that the charity faced not only a Charity Commission inquiry, but serious reform of its policies, practices and finances? It should benefit the former mining communities it was founded to serve, instead of constructing a £30 million ivory tower for the future.
Like my hon. Friend, I have constituents who use proportional representation to elect people to local government or the Scottish Parliament. Does he agree that we have to learn lessons from both the positive and the negative elements in those electoral systems?
The hon. Lady is making a very passionate speech, and she is certainly right that we have to change our political culture, but I would slightly challenge her. We have a slightly more proportional system in Scotland, but it has not led to a different culture in the Scottish Parliament. The Scottish Government get elected on 30-odd per cent of the vote and pretend they speak for the entire nation, unilaterally. Does the hon. Lady agree that although proportional representation could be part of how we resolve the issue, a wider change in culture is required as well?
My hon. Friend the Minister is being very generous with taking interventions. Does he agree that SNP-run Glasgow city council’s decision to cut school librarians was a mistake and has a detrimental impact on kids’ education?
I welcome this Green Paper, which is both timely and forward looking. The Government are right to respond to the fact that people get much of their news from social media nowadays. As more and more people turn to artificial intelligence chatbots for news and information, what work are the Government doing to ensure that trusted sources of information are given prominence?
Thank you. I call Harriet Cross.