Baby Loss
It is a great privilege to follow the hon. Member for Rossendale and Darwen (Andy MacNae). I thank him for working with me and the hon. Member for Sherwood Forest (Michelle Welsh) to secure the debate, and I thank my many colleagues on the all-party parliamentary group on patient safety. I would also like to thank the Secretary of State for Health and Social Care, the right hon. Member for Ilford North (Wes Streeting), for being here himself today. It means an enormous amount to families up and down the country to see that commitment from him. I know it is an issue in which he has taken enormous personal interest. I think the most difficult meeting I had when I was doing his job many years ago was with a man called Carl Hendrickson, who came to see me a few days before I stood at that Dispatch Box to give the statement on the Morecambe Bay inquiry. Carl lost both his wife and his son at Morecambe Bay NHS Foundation Trust. A midwife mistook some fitting by his wife as just fainting. His wife died an hour later from an embolism. The next day, his son Chester died from brain damage. He came to see me with his 11-year-old son, Conrad. I will never forget it, because it was obviously going to be a very difficult meeting and I asked him whether he would like his son to sit outside with some of the civil servants while we discussed what happened. He said no, because he wanted his son to know, for the rest of his life, that he had taken his concerns about what went wrong right to the very top and asked awkward questions. And that was what he did. I owe a great debt to the Morecambe Bay families: to Carl and to Simon Davey, Liza Brady, James Titcombe and many others. The American thinker Margaret Mead had a saying: “Never doubt that a small group of thoughtful committed individuals can change the world; indeed, it’s the only thing that ever has.” For me, those Morecambe Bay families were that small group of thoughtful, committed people, along with the families from Mid Staffs, Shrewsbury and Telford, East Kent, Nottingham and many other places. As we reflect in this very sad and meaningful Baby Loss Awareness Week about what has gone wrong, it is also important to remember that progress has been made since then. Since the Morecambe Bay inquiry, the overall number of baby deaths is down by about 20%. That is about 700 fewer a year, or two fewer a day. The NHS is better than it was about being honest about mistakes. There have been a lot of reforms. We have a chief inspector of hospitals and a CQC that is set up to call a spade a spade when there is poor care. We have the duty of candour, which will be further strengthened by the new Hillsborough law. We have medical examiners, we have Martha’s rule and we have “freedom to speak up” guardians. Despite those improvements, there are some warning signs. Since the pandemic, the decline in baby deaths has plateaued. The number of maternal deaths has actually increased. As the hon. Member for Rossendale and Darwen just said, there is big inequality. You are far more likely to die as a black or Asian mum. You are far more likely to die as a black or Asian baby, or a baby from a deprived background, than other babies. Still we have a third of NHS staff, according to the staff survey last year, saying that they are afraid to raise safety concerns, and half saying that they do not think anything will happen if they do. The thing that is so important to remember—I have said this to the House on many occasions—is that if you are in a birthing unit and present at a C-section and something goes wrong, there is nothing as a professional that you want more than to be open, honest and transparent about what happened, so that lessons can be learned and you can make sure that mistake never happens again. But our system makes that practically impossible. We have the CQC, the NMC, the General Medical Council and the trust. Lawyers get involved and people worry. There is jeopardy for clinicians: that if they are honest and open about the ordinary human mistakes that anyone can make, they will be punished for it. The result is that the one thing that needs to happen more than anything else—truthfulness to the bereaved families and learning the lessons so that the tragedy is not repeated—can be the very thing that does not happen at all. Instead, we get a five-year legal process happening and the truth is not established for maybe five, six or seven years after that. So what needs to happen to put it right? We all have our lists of things, and I echo absolutely everything that was said in the wonderful speech before mine. For me, first of all, it is absolutely essential that we get the CQC back on its feet. It went badly wrong, but under new leadership that the Secretary of State has put in place, I believe it is now going in absolutely the right direction. We must return to the one-word ratings so that parents and families know absolutely whether the care in their local hospital or NHS organisation is safe. That is really important. Secondly, we have a litigation culture. At the moment we spend about £3.5 billion annually in maternity awards for where maternity care has gone wrong, which is not far off the £4 billion total cost of all NHS maternity units. It has gone so badly wrong that many parents think that when something goes wrong, their only friend is not a doctor but a lawyer—that cannot be right. We need to have much better accountability. The Government are rightly absolutely committed to bringing back family doctors. People having their own GP would make an enormous difference, because at the moment there is no one inside the NHS to turn to when these things go wrong, and going back to the system of everyone having their own GP could make a really big difference to that. We need to support the work of brilliant charities such as Tommy’s, Sands, the Clinical Human Factors Group and Baby Lifeline in their contribution to making maternity care safer. We also need to tackle the dangerous culture of “normal” births, which still sees too many mothers steered away from getting a surgical intervention when that would be the safest route for them and their baby. Those are all important changes. I would like to say one final thing, which is that we must not return to a targets culture. I have some concerns about the new NHS league tables. I know they are set up with the best of intentions, but safety and quality is not one of the factors that ensures a move up the list. I know the Secretary of State will take great care in the way that those are implemented, but I think it is really important that there is always a bottom line—a floor—on safety and quality below which the system never goes. What I really want to say to the House, in conclusion, is that we must not lose hope. If we had the same levels of maternity safety as Sweden, one fewer baby would die every day; if we got to the same levels as Japan, two fewer babies would die every day. If we could get the NHS back on the trajectory it was on in the years leading up to the pandemic, we would be able to get to care as safe as Sweden’s in the next five or six years, so it really is something within our grasp. I will finish by saying this. The NHS was set up on the premise of equality, and the idea that no matter who we are—whether we are rich or poor, young or old, from the north or the south, from the city or the country—everyone should be able to access the healthcare they need. Everyone means every baby, too. We talk about safety more than any other healthcare system in the world. In this very sad week, when we remember all the people who have lost their dear babies and their dear loved ones in the process of having babies, let us redouble our efforts to make the NHS the safest, highest-quality healthcare system in the world.