Ockenden Report — House of Lords, 2022-03-30
Topic: Health
Gillian Merron (Labour, Centre-left): My Lords, I thank the Minister for bringing this Statement to your Lordships’ House and for the reassurances he has given and the actions that have been, and will be, taken. I listened to this Statement in great sadness and shock, as I know that so many others have as they heard the news unfold. I will start by expressing heartfelt gratitude to the families who came forward. We would not be here today had it not been for their persistence and the resilience they have shown across over 20 years in their fight for justice. I also thank Donna Ockenden and her team for this landmark report. I utterly regret the appalling circumstances in which it has come before us Today marks an important milestone for hundreds of bereaved families who are seeking justice. As the Minister said, it is not the end, because West Mercia Police are investigating some 600 cases. This report lays bare the disturbing truth of what families have had to face and why their fight for justice has been so fierce. The inquiry examined cases involving nearly 1,500 families in instances crossing over decades. It concluded that hundreds of babies were stillborn, died shortly after birth or were left severely brain damaged, and that mothers died giving birth while others were made to have natural births despite the fact that they should have been offered a caesarean. This must have been cruel. The report says that over 200 babies and nine mothers might have survived if they had received the right care In addition to what we have read about the actual circumstances, the report also has huge implications for the future of maternity care. The report, of course, makes for harrowing reading—cries for help going unheard; parents having to try to resuscitate their own children because there was no one there to help; and women and babies dying needlessly because the mothers were not listened to. That women were silenced and ignored at their most vulnerable, when they were relying on the NHS to keep them and their babies safe, is shameful. In addition to the NHS, the CQC also failed in its duties as it missed opportunities to stop the poor maternity care No woman should ever have to face going into hospital to give birth not knowing whether she and her baby will come out alive. However, these were not just one-offs or isolated incidents of negligence. There was an institutional failing in a system riddled with a toxic culture of bullying, ignoring mothers and deliberating keeping caesarean rates low, even though that was not the right thing for the mother. The entire culture failed to take up the many opportunities to realise that there was a serious problem and to act. We are where we are today because of the persistence and resilience of the families who have suffered, and continue to suffer, and because of their refusal to give up the fight to expose these failings The only comfort we can offer them is that their voices have been heard, and that we commit today, in your Lordships’ House, to ensure that these failings are never repeated. For too long, patient safety issues and the voices of women have been an afterthought, leading to the kind of crisis we saw in this NHS trust—and this must change. There can be no compromise on patient safety, which has to be a priority for both health professionals and Ministers With this in mind, I will put some points to the Minister. I certainly welcome the acceptance of all 84 recommendations, but how will the Minister monitor the progress that is being demanded through these recommendations, and when and how will this be reported to Parliament The report makes it clear that safe services cannot be run unless there is a culture of transparency and accountability. Can the Minister therefore explain how he intends to ensure an open culture within the NHS, with a willingness to learn, particularly within maternity services, and for future failures to be identified and corrected quickly Underpinning issues in maternity care, as is the case across so much of our NHS, is the workforce, which is why we have been pushing so hard on this matter in the Health and Care Bill. The NHS is now losing midwives faster than it can recruit them. A recent CQC survey shows that almost a quarter of women were unable to get help when they needed it during labour. Hundreds of pregnant women were turned away from maternity wards last year because there were not the staff available to care for them. What is being done to ensure that the NHS can recruit the midwives that it needs? What is being done to keep the midwives we have in post It is only with the necessary workforce that the NHS will be able to ensure that women receive the care that meets their needs and prioritises their safety. That security and respect is all that the families who suffered so much at Shrewsbury want, and it is all that the women who put their and their babies’ lives in the hands of the NHS want. This has to be reasonable, and it has to be done.