Nottingham Maternity and Neonatal Services
I thank the Secretary of State for advance sight of his statement and Donna Ockenden and her team for the care and compassion with which they conducted the review. We had a meeting with her yesterday, and I have to say that it was probably one of the most difficult meetings that I have ever had. I pay tribute to the hon. Member for Sherwood Forest (Michelle Welsh). I can see how deeply personal and painful this is, and I admire her and all her colleagues from the region at what must be a very difficult moment. Let me say from the outset that I want to be constructive in opposition when it comes to this issue. We need to work together; we have to see improvements. I begin with the women, babies, fathers, partners and families whose lives sit behind the review’s findings. To them, we owe a profound apology for failing them when a family should feel safest, most supported and most able to trust the care around them. For too many, that trust was broken; women were not listened to, families were not believed and warning signs were missed. Some suffered the deepest lost, others were left physically unsafe and others psychologically scarred. No statement can repair that pain, but it can mark the point at which testimony becomes responsibility, and responsibility becomes action. The painful truth is not only that the failings occurred but that the themes are familiar: women not heard, families dismissed, poor communication, missed deterioration, weak governance and people unable to speak up. Maternity and neonatal safety has challenged Governments of both parties, but it would be wrong to let that history soften the urgency. Women and families are tired of telling their story, hearing promises and seeing the same themes return. The question is whether the system will move because of this review, and so I put three tests to the Secretary of State. The first is the listening test. Women and families were not consistently listened to. Their concerns were too often dismissed or not acted upon. That is not a soft issue; it is a safety issue. How will the Government embed listening as a clinical discipline? How will trusts measure whether women feel heard? Will complaints and near misses be treated as information for improvement? The second is the culture test. The review describes bullying, hierarchy and poor psychological safety affecting staff’s decisions and willingness to escalate. I pay tribute to those who were brave enough to do so. In maternity and neonatal care, minutes matter. If staff cannot challenge, safety is weakened. Staff cannot provide the care they want to if they are exhausted or unsupported, or if hierarchy matters more than candour. So I ask: how will boards be held accountable for that ward culture? The third test is the delivery test. Harm rarely followed one error; it usually followed a chain of poor communication, weak risk assessment, delayed escalation, staff pressure, inadequate governance and missed learning. The response cannot be a single announcement. It must be accompanied by a delivery plan, so will the Secretary of State publish a national implementation plan with named accountability, delivery dates and regular updates to this House? That plan must address the workforce so that staff have the support and information they need to fulfil their roles to the ability they wish. That plan must design services for today and the future, not rely on assumptions from the past. Women are having children older, pregnancies are more complex and more women are entering pregnancy with pre-existing conditions, previous loss, fertility treatment, mental health needs or circumstances shaping care. That means a need for practical, personalised care, informed choice and each woman being treated as a whole. The review also requires us to confront inequalities. The safety of a patient must not depend on confidence, class, ethnicity, language or an ability to fight through the system. The issue with our mortuaries is also really shocking. The horror stories that we have heard must never happen again. Is the Secretary of State working with colleagues in the Department of Justice to see what more needs to be done to overhaul this area? Finally, we must recognise the psychological harm caused through silence, poor communication, lack of bereavement support and the battle for honesty. We know that our mortuaries need to have the highest standards. Compassion after harm is not a courtesy; it is a duty. Trust is rebuilt when women feel the difference in the room, when words change decisions, when staff speak without fear, when risk is escalated in time and when boards are judged by results. Where the Government act to improve safety, accountability, staffing and family voice, they will have our support so that we can see this through together. Where they do not, they will face our scrutiny. This review began with families who had to fight to be heard. The task now is to ensure that no family has to fight so hard again.