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Maternity Services (Morecambe Bay)

Volume 593: debated on Tuesday 3 March 2015

With permission, Mr Speaker, I would like to make a statement on the independent investigation into the care of mothers and babies at the University Hospitals of Morecambe Bay NHS Foundation Trust, which is being published today.

I commissioned this report in September 2013 because I believed there were vital issues that needed to be addressed following serious incidents in maternity services provided by the trust dating back to 2004.

There is no greater pain for a parent than to lose a child, and to do so knowing it was because of mistakes that we now know were covered up makes the agony even worse. Nothing we say or do today can take away that pain, but we can at least provide the answers to the families’ questions about what happened and why, and in doing so try to prevent a similar tragedy in the future.

We can do something else, too, which should have happened much earlier—and that is, on behalf of the Government and the NHS, to apologise to every family who have suffered as a result of these terrible failures. The courage of those families in constantly reliving their sadness in a long and bitter search for the truth means that lessons will now be learned so that other families do not have to go through the same nightmare. We pay tribute to those brave families today.

I would especially like to thank Dr Bill Kirkup and his expert panel members. This will have been a particularly difficult report to research and write, but the thoroughness and fairness of their analysis will allow us to move forward with practical actions to improve safety, not just at Morecambe Bay, but across the NHS.

I know that before we discuss the report in detail the whole House will want to recognise that what we hear today is not typical of NHS maternity services as a whole, where 97% of new mothers report the highest levels of satisfaction. Our dedicated midwives, nurses, obstetricians and paediatricians work extremely long hours providing excellent care in the vast majority of cases. Today’s report is no reflection on their dedication and commitment, but we owe it to all of them to get to the bottom of what happened so we can make sure it never happens again.

The report found 20 instances of significant or major failings of care at Furness general hospital, associated with three maternal deaths and the deaths of 16 babies. It concludes that different clinical care would have been expected to prevent the death of one mother and 11 babies.

The report describes major failures at almost every level. There were mistakes by midwives and doctors, a failure to investigate and learn from those mistakes and repeated failures to be honest with patients and families, including the possible destruction of medical notes.

The report says that the dysfunctional nature of the maternity unit should have become obvious in early 2009, but regulatory bodies including the North West strategic health authority, the primary care trusts, the Care Quality Commission, Monitor and the Parliamentary and Health Service Ombudsman failed to work together and missed numerous opportunities to address the issue.

The result was not just the tragedy of lives lost, but indescribable anguish for the families left behind. James Titcombe speaks of being haunted by “feelings of personal guilt” about his nine-day-old son who died. “If only”, he says, “I had done more to help Joshua when he still had a chance”. Carl Hendrickson, who worked at the hospital and lost his wife and baby son, told me that he was asked to work in the same unit where they had died and even with the same equipment that had been connected to his late wife. Simon Davey and Liza Brady told me that the doctor who might have saved their son Alex was shooed away by a midwife, with no one taking responsibility when he was tragically born dead.

In short, it was a second Mid Staffs, where the problems—albeit on a smaller scale—occurred largely over the same period. In both cases perceived pressure to achieve foundation trust status led to poor care being ignored and patient safety being compromised, and in both cases the regulatory system failed to address the problems quickly. In both cases families faced delay, denial and obfuscation in their search for the truth, which in this case meant that at least nine significant opportunities to intervene and save lives were missed. To those who have maintained that Mid Staffs was a one-off “local failure”, today’s report will give serious cause for reflection.

As a result of the new inspection regime introduced by this Government, the trust was put into special measures in June 2014. The report acknowledges improvements made since then, which include more doctors and nurses, better record keeping and incident reporting, and action to stabilise and improve maternity services, including a major programme of work to reduce stillbirths. The trust will be re-inspected this summer when an independent decision will be made about whether to remove it from special measures. Patients who use the trust will be encouraged that the report says it

“now has the capability to recover and that the regulatory framework has the capacity to ensure that it happens”.

The whole House will want to support front-line staff in their commitment and dedication during this difficult period.

More broadly, the report points to important improvements to the regulatory framework, particularly at the Care Quality Commission which it says is now

“capable of effectively carrying out its role as principal quality regulator for the first time…central to this has been the introduction of a new inspection regime under a new Chief Inspector of Hospitals”.

As a result of that regime, which is recognised as the toughest and most transparent in the world, 20 hospitals—more than 10% of all NHS acute trusts—have so far been put into special measures. Most have seen encouraging signs of progress, with documented falls in mortality rates. There remain many areas where improvements in practice and culture are still needed. Dr Kirkup makes 44 recommendations—18 for the trust to address directly, and 26 for the wider system. The Government received the report yesterday and will examine the excellent recommendations in detail before providing a full response to the House.

There are, however, some actions that I intend to implement immediately. First, the NHS is still much too slow at investigating serious incidents involving severe harm or death. The Francis inquiry was published nine years after the first problems at Mid Staffs, and today’s report is being published 11 years after the first tragedy at Furness general hospital. The report recommends much clearer guidelines for standardised incident reporting, which I am today asking Dr Mike Durkin, director of patient safety at NHS England, to draw up and publish. I also believe that the NHS could benefit from a service similar to the air accidents investigation branch of the Department for Transport. Serious medical incidents should continue to be investigated and carried out locally, but where trusts feel that they would benefit from an expert independent national team to establish facts rapidly on a no-blame basis, they should be able to do so. Dr Durkin will therefore look at the possibility of setting up such a service for the NHS.

Secondly, although we have made good progress in encouraging a culture of openness and transparency in the NHS, the report makes it clear that there is a long way to go. It seems that medical notes were destroyed and mistakes covered up at Morecambe Bay, quite possibly because of a defensive culture where the individuals involved thought that they would lose their jobs if they were discovered to have been responsible for a death. Within sensible professional boundaries, however, no one should lose their job for an honest mistake made with the best of intentions; the only cardinal offence is not to report that mistake openly so that the correct lessons can be learned.

Recent recommendations from Sir Robert Francis on creating an open and honest reporting culture in the NHS will begin to improve that, and I have today asked Professor Sir Bruce Keogh, medical director of NHS England, to review the professional codes of both doctors and nurses, and to ensure that the right incentives are in place to prevent people from covering up instead of reporting and learning from mistakes. Sir Bruce led the seminal Keogh inquiry into hospitals with high death rates two years ago that led to a lasting improvement in hospital safety standards and has long championed openness and transparency in health care. For this vital work he will lead a team that will include the Professional Standards Authority for Health and Social Care, the General Medical Council, the Nursing and Midwifery Council, and Health Education England, and he will report back to the Health Secretary later this year.

The report also exposed systemic issues about the quality of midwifery supervision. While the investigation was under way, the King’s Fund conducted a review of midwifery regulation for the NMC, which recommended that effective local supervision needs to be carried out by individuals wholly independent from the trust they are supervising. The Government will work closely with stakeholders to agree a more effective oversight arrangement, and will legislate accordingly. I have asked for proposals on the new system by the end of July this year.

For too long the NMC had the wrong culture and was too slow to take action, but I am encouraged that it has recently made improvements. Today it has apologised to the families affected by events at Morecambe Bay, and it is investigating the fitness to practise of seven midwives who worked at the trust during that time. It will now forensically go through any further evidence gathered by the investigation, to ensure that any wrongdoing or malpractice is investigated. Anyone who is found to have practised unsafely or who covered up mistakes will be held to account, which for the most serious offences includes being struck off. The NMC also has the power to pass information to the police if it feels that a criminal offence may have been committed, and it will not hesitate to do so if its investigations find evidence to warrant that. The Government remain committed to legislation for further reform of the NMC at the earliest opportunity.

The report expresses a “degree of disquiet” over the initial decision of the Parliamentary and Health Service Ombudsman not to investigate the death of Joshua Titcombe. I know the Public Administration Committee is already considering these issues, and will want to reflect carefully on the report as it considers improvements that can be made as part of its current inquiry.

Finally, I expect the trust to implement all 18 of the recommendations assigned to it in the report. I have asked Monitor to ensure that that happens within the designated time scale, as I want to give maximum reassurance to patients and families who are using the hospital that no time is being wasted in learning necessary lessons. We should recognise that despite many challenges, NHS staff have made excellent progress recently in improving the quality of care, with the highest ever ratings from the public for safety and compassionate care. The tragedy we hear about today must strengthen our resolve to deliver real and lasting culture change so that these mistakes are never repeated. That is the most important commitment we can make to the memory of the 19 mothers and babies who lost their lives at Morecambe Bay, including those named in today’s report: Elleanor Bennett, Joshua Titcombe, Alex Brady-Davey, Nittaya Hendrickson and Chester Hendrickson. This statement is their legacy, and I commend it to the House.

I thank the Secretary of State for his well-judged statement, and echo entirely the sentiments he expressed. Families in Barrow and the wider Cumbria area were badly let down by their local hospital and by the NHS as a whole. The Secretary of State was right to apologise to them on behalf of the Government and the NHS, and today I do the same on behalf of the previous Government.

It is hard to imagine what it must be like to lose a child or partner in such circumstances, but to have that suffering intensified by the actions of the NHS is inexcusable. Bereaved families should never again have to fight in the way that these families have had to fight to get answers. The fact that they have found the strength and courage to do so will benefit others in years to come, and I pay tribute to them all, and particularly to James Titcombe.

This report finally gives the families the answers that they should have received many years ago. It explains in detail what went wrong, the appalling scale of the failings and, as the Secretary of State said, the opportunities missed to identify those failings and put them right.

I echo the Secretary of State’s praise for Dr Bill Kirkup, his investigation team and the panel that assisted them. The report’s analysis is thorough, and its recommendations are powerful but proportionate. The Opposition support all the recommendations made today. I understand that the Secretary of State will want to take time to consider each individually, but he can rely on our full support in introducing them at the earliest opportunity.

People’s first concern will be whether local services are safe today. The report identifies the root cause of the failures as a dysfunctional local culture and a failure to follow national clinical guidance. There are suggestions in the report that that culture has not entirely disappeared. The report finds:

“we…heard from some of the long-standing clinicians that relations with midwives had not improved and had possibly deteriorated over the last two to three years…we saw and heard evidence that untoward incidents with worryingly similar features to those seen previously had occurred as recently as mid-2014.”

I am sure the fact that problems have been acknowledged means that there has already been significant improvement, but will the Secretary of State say more about those findings, and about what steps he is taking to ensure that the trust now has the right staff and safety culture?

After safety, people will rightly want accountability, as the Secretary of State said, not just for the care failings, but for the fact that the problem was kept hidden from the regulators and the public for so long. When information came to light, it was not acted on. Lessons were not learned, and problems were not corrected. The investigation recommends that the trust formally apologises to those affected. The whole House will endorse that call, and will want it done both appropriately and immediately. Further, will the Secretary of State ensure that any further referrals to the GMC and NMC are made without delay? Will he also ensure that any managerial or administrative staff found guilty of wrongdoing are subject to appropriate action? A number of staff have left the trust in recent years, many with pay-offs. Will he review those decisions in the light of the report and take whatever steps he can to ensure that those who have failed are not rewarded?

One of the central findings of the investigation is on the challenges faced by geographically remote and isolated communities in providing health services. The investigation warns of the risks of a closed clinical culture in which

“practice can ‘drift’ away from standards and procedures found elsewhere”.

Is not the report right to recommend a national review of maternity care and paediatrics in rural and isolated areas, and will the Secretary of State take that forward? Alongside that, there are concerns about the sustainability of the Cumbrian health economy. My hon. Friend the Member for Copeland (Mr Reed) has today written to the chief executive of NHS England to call for a review of the specific challenges it faces. I hope the Secretary of State will be sympathetic to that call.

On the CQC, the role of the regulator has always been to oppose poor care and challenge practice, but it is clear that it failed in its duty in this case. Given what was known, the decision to register the trust without conditions in April 2010 was inexplicable, as was the decision to award foundation trust status later in 2010, as was the decision to inspect emergency care pathways but not maternity services—in so doing, it failed to act on specific warnings. As the report states, there was and remains confusion in the system over who has overall responsibility for monitoring standards, with overlapping regulatory responsibilities. The Opposition support moves to make the CQC more independent, but does the Secretary of State agree that the journey of improvement at the regulator needs to continue, and that there is a need for further reform? Will he ensure that NHS England draws up the recommended protocol on the roles and responsibilities for all parts of the oversight system without delay, and does he agree that the CQC should take prime responsibility?

I want to close by focusing on two proposals that I believe get to the heart of the matter before us. I have thought carefully about how we truly do justice to the families’ campaign and learn the lessons of both this investigation and the Francis report. In my view, the answer is a much more rigorous system of the review of all deaths in the community and in hospitals than currently exists.

First, is the reform of death certification and the introduction of a new system of independent medical examination well overdue? The Kirkup report echoes findings that go back as far as Dame Janet Smith’s inquiry into the Shipman murders, which were repeated recently by Sir Robert Francis in his two reports on Mid Staffordshire. The previous Government legislated for those reforms and made provision for the independent scrutiny by a medical examiner of all deaths that are not referred to a coroner. That has been piloted and proven to be effective. The investigation says that those reforms could have raised concerns at Morecambe Bay before they eventually became evident.

The second point is that we need a better system for scrutinising deaths in hospital. The report recommends mandatory reporting and investigation of serious incidents of all maternal deaths, stillbirths and unexpected neonatal deaths. Is there not a case to go further, including by looking at moving to a mandatory review of case notes for every death in hospital, and at how we can use a standardised system of case note review to support learning and improvement at every trust?

To help to guide the Opposition’s new approach to quality improvement, Professor Nick Black has agreed to advise us and inform the review, which will be concluded by the end of the month. In our view, that reform is much needed, because rather than looking at a sample of deaths to avoid harm, we would look at every single death to learn lessons, which means that every single person matters. Ideally, the review should be cross-party. I hope the Secretary of State feels able to endorse the review I have announced, which will make recommendations that the next Government can act on immediately. Is that not the best way to do justice to the issues that the families have fought to raise, and to ensure that the legacy of their campaign is to ensure that no others go through what they have gone through?

I thank the right hon. Gentleman for his measured tone. I am sure he is absolutely sincere in wanting to learn from this tragedy. I thank him for his moving words and for his apology. He will understand that there is nervousness among the families because, in the past, when the Government have talked about rooting out poor care, we have been accused of running down the NHS. We have had a different tone today, and I welcome it.

To answer the right hon. Gentleman’s specific points on the quality of care at the hospital currently, the best person and people to make that judgment are the new CQC and chief inspector of hospitals, Professor Sir Mike Richards. He has said that, in his view, the care at the maternity unity in Furness general hospital is good, and indeed safe—it is more than safe; it is good. That should reassure many people who are using the hospital. He is also very clear that there are many, many improvements to make, and his overall rating for the trust is not good. The report highlights many areas that still need to be addressed, but it is important to give that reassurance.

On death certification, I assure the right hon. Gentleman that we fully support that policy. As he knows, it was recommended in January 2005, so it has taken a long time for both Governments to address. We fully support the policy and have had successful trials. We are committed to introducing it as soon as possible and we want to go further. There may be some common ground, because we, too, have been talking to Professor Nick Black about case note reviews. The latest advice I have had is that it would be technically very difficult to review the case notes of all the 250,000 deaths every year in NHS hospitals, because of the resource implications and the doctors’ time it would take. I asked whether it would be possible to do that. I was advised that, if we looked at case notes hospital by hospital, there would be a risk of trusts getting into big disputes about whether or not a death was avoidable. I asked Professor Black to help me to devise a methodology so that we can assess the level of avoidable deaths by hospital trust. We would be the first health economy in the world to do that. I hope we will have his full support as we take that forward.

On the decision to give the trust foundation trust status, the report makes it clear that Ministers were advised that they had no locus to intervene, because the process had already been set in train—the decision had been deferred but not stopped, so they were not able to intervene. It is clear that the level of knowledge in the Department of Health, as in the rest of the system, was wholly inadequate given what was happening in that hospital.

I should like to make one other point, on a comment made by Labour this morning that the report would say that the failings were very localised. In fact, the report says the opposite. I want to read what Dr Kirkup says in the introduction to the report:

“It is vital that the lessons, now plain to see, are learnt and acted upon, not least by other Trusts, which must not believe that ‘it could not happen here’.”

It is important that we take that lesson from the report extremely seriously.

I would like to finish on a note of consensus. I appreciate that it is not always easy for Oppositions to support the Government publicly as they put right policy mistakes that they have inherited, but I think there is one thing where we can make common ground: the need for culture change in the NHS. Policies can be changed over one Parliament, but culture change takes a generation. What the families who have suffered so much want to know more than anything else is that Members on all sides of the House are committed to that, so that we never again go back to the closed ranks and institutional self-defence that piled agony on to their tragedies, and that, once and for all, we all make the commitment that patients will always come first.

As a Member of Parliament for an area covered by the trust, I assure the Secretary of State that many thousands of workers in the NHS in my area do a really good job in very difficult geographical circumstances.

I was newly elected to Parliament in 2010. My experience, alongside that of colleagues whom I see in the House, as a constituency MP dealing with the huge institution that is the NHS has been that it is difficult to find out who is responsible, where and for what. Like everybody else, my heart goes out to the parents. I do not know how they have struggled on, with their loss and with being confronted with what almost seems like a professional or administrative closing of ranks and doors to their pleas for some information on what happened. It is just unbelievable.

My constituents do not understand why—this is mentioned in the report—a major incident in 2004 was not looked at. There were five more major incidents in 2006-07 and another five in 2008, yet still nothing was done. What will the Secretary of State do to reassure my constituents that when a major incident happens again—as presumably it could in any NHS hospital across the country—it will be acted on?

I am happy to do that. In fact, I can not only tell my hon. Friend what we are going to do, I can tell him what we have done. The main purpose of the new CQC inspection regime, with a chief inspector of hospitals and a special measures regime, is to make sure that these issues come to light much more quickly. The new regime has been very active: 20 trusts—more than 10% of all trusts in the NHS—have gone into special measures. We have seen dramatic improvements.

I would like to make a broader point to my hon. Friend’s constituents. He speaks very wisely when he says that this is not about the dedication and commitment of front-line staff. He is absolutely right. The Royal Lancaster infirmary is not the main focus of the Kirkup report, but of course as part of the same trust it suffered from the same management failings. There are Members of this House who have had problems at the Royal Lancaster infirmary and found that they were not listened to when they made complaints, because proper management was not in place. That will have affected his constituents. I hope they will take encouragement from the changes that have happened recently in that regard.

I thank the Secretary of State for the dignified and fitting way in which he was able to name some of the grieving parents and the babies they lost. We cannot escape the painful conclusion from the report that our hospital was compromised by some shocking failures in care and a deeply inappropriate defensiveness from certain individuals. Does he agree that the scale of failure laid out in the report may well serve to reopen the criminal investigation? Will he support the healing process that is now needed in our community, with resources if necessary, so that we can move on from this? Finally, will he set out a timetable by which he will look through all the recommendations and report back to the House on whether the Government will accept them? Will that be before the election?

I do not know the answer to the last question because we have received the report only very recently, but we will do this work as soon as possible. Indeed, if we have cross-party support, it may be that we can expedite the process. The hon. Gentleman worked very closely with James Titcombe and is absolutely right to talk about the seriousness of what happened. As with the Francis report, however, I would caution against the idea that this problem will be solved if a few more nurses are struck off. We need accountability—that is incredibly important—and where there is wrongdoing, people must be fully held to account. The big lesson is the lack of openness, transparency and trust. It is quite possible that the reason some people did not speak out about poor care is that they were frightened of the consequences of doing so. They thought they would not be listened to. Other industries, such as the nuclear industry in which James Titcombe worked or the airline industry, have managed to create a culture of trust where people on the front line who make mistakes feel able to speak out and be supported if they do so. That is the most important lesson we need to learn from today’s report.

I, too, want to the thank the Secretary of State and the shadow Secretary of State for their entirely appropriate contributions, both the statement and the response, on this immensely sensitive and deeply personally upsetting series of circumstances. I want especially to pay tribute to the families who lost loved ones as a result of what Dr Kirkup referred to as

“serious failures of clinical care”.

He refers to the report as a damning indictment.

The dignity and determination of parents such as James Titcombe and Carl Hendrickson have led to this awful truth being laid bare today. Those parents are an inspiration to me, and they should be to all of us. I want to pick up on one point in particular that was raised during the Secretary of State’s statement. Dr Kirkup expresses disquiet that the NHS and the parliamentary ombudsman chose not even to investigate what has now been shown to be the needless deaths of at least 11 babies and at least one mother. May I press the Secretary of State to go further than he has in his statement and do everything in his power to ensure that the watchdog for patients is not a lapdog for senior managers? Patients need a powerful, effective independent investigator who listens to those who grieve, like the Morecambe Bay families, and not one who dismisses them without even an investigation.

My hon. Friend is absolutely right. There were, clearly, very serious flaws in the way the Parliamentary and Health Service Ombudsman operated, particularly in the case of Joshua Titcombe. My hon. Friend will know that the PHSO is accountable to this House through the Public Administration Committee, and not through the Government and the Department of Health. The Public Administration Committee is considering this issue in a great deal of detail to see what lessons need to be learned. I think one of the issues is the level of expertise within the PHSO and, with the greatest of respect, a certain lack of confidence in its ability to understand when there has been a clinical failure. I think everyone agrees that one of the things we need to do is to ensure that it can draw on medical expertise. It needs to make sure that its culture is as open and transparent as the culture it would like to see inside the NHS.

The Secretary of State said that the fitness to practise of seven midwives is currently being considered by the National Midwifery Council. Given that this matter goes back over a decade, were any health professionals, either doctors or nurses, referred to their regulatory bodies during any of the incidents he outlined earlier?

I am not aware that they were. If that turns out to be the case, that would be extremely worrying. Since Dr Kirkup started his investigation, he has been in touch with the regulatory bodies throughout the process. He has not waited until today to refer back to them any names of people where he thinks there may be a concern.

I thank my right hon. Friend for his deep and meaningful statement. In my constituency, the effects of what has happened in our trust have been deeply felt. I would also like to reach out to my hon. Friend outside the Chamber, the hon. Member for Barrow and Furness (John Woodcock). We have to put everything behind us. In my constituency, there is a campaign which says that the hospital is closing. The staff and the new management are beside themselves on this particular issue. Does my right hon. Friend agree that this has now got to stop? Hospitals and A and Es were never going to close down. At the end of the day, the staff are the only people who are going to suffer in all this.

I think this is a time when the whole House needs to unite behind the staff in that trust, who are working very hard to turn the situation around; indeed, they have made great progress. I had to call Nicola Adam of The Visitor to reaffirm the point that there are absolutely no plans to close the hospital. I hope the whole House will recognise that statement for what it is and that hon. Members will reiterate it in all their communications with their constituents.

I thank the Secretary of State and my right hon. Friend the Member for Leigh (Andy Burnham) for the tone of the statement and the Opposition’s response. I want to ask the Secretary of State about the point he made in his statement about the relationship between clinicians and midwives, which Dr Kirkup identified as having deteriorated over the last two or three years. He said that there was evidence of untoward incidents, with worryingly similar features to those that had previously occurred, as recently as last year. The Secretary of State mentioned extra numbers, but is he confident that the relationship between midwives and doctors is now resolved and that we have safe care at that hospital and elsewhere?

I think we can trust the CQC’s view that the care in the maternity unit is safe, but the hon. Gentleman is absolutely right to draw attention to the issue of the barriers between doctors and midwives, which is striking. That goes back a very long time: there seemed to be a kind of macho culture among the midwives to do with not letting the doctors in, which probably led to babies needlessly dying, which is the great tragedy. Making sure that that culture is changed, so that the patient’s needs are always put first, is obviously a massive priority. I know that the trust has made great strides in that area, but we all understand too that it takes time to change culture, and we need to support it as it goes on that journey.

I join the Secretary of State in paying tribute to James Titcombe and all the families who have fought so long for answers. I also thank Dr Kirkup for his excellent report. I welcome the action that the Secretary of State has announced today, but can he add to that list by saying whether we can bring forward having medical examiners to look into the cause of death before the end of this Parliament and, if not, say what the barriers to introducing that much overdue reform are? Will he also touch on recommendations 20 and 21 in the report, which refer to the need for a national review of maternity and paediatric services in areas that are remote, isolated and hard to recruit to? Indeed, the report goes further and says that the problem extends beyond those services. This is an issue we need to address to improve safety without deterring recruitment in these areas.

I am afraid I can only commit now to us introducing independent medical examiners as soon as possible. We are wholeheartedly committed to this. It is incredibly important for relatives, because where they have a concern about a death and possibly a mistake being made in someone’s care in their final hours, the availability of an independent examiner has been shown in the trials we have run to be very effective, so we are committed to doing that.

I should have answered the shadow Health Secretary on the point about a review of maternity services, because he raised it as well. NHS England is doing that review; we have already announced that to this House. Today it is publishing the terms of reference of that review. That is important, because there has been a big debate inside the health service—a debate with which many people will be familiar—about what the minimum appropriate size for maternity and birthing units is, and we need to get to the bottom of the latest international evidence.

During the period when I was writing the report on complaints in hospitals, I met Mr Titcombe. I was impressed by his persistence, because persistence is what anyone who is trying to tackle a complaint needs. I understand what he means when he says he is haunted by personal grief: I think of all those parents and relatives who have waited all this time to try to get some answers to their questions. The length of time it takes to answer people’s complaints is still not satisfactory. I myself have waited over two years and three months and I still do not have answers—I know that is not in his bag, but it is generally true of the whole of the United Kingdom. I support what my right hon. Friend the shadow Secretary of State said in calling for the medical scrutiny of all deaths that are not referred to a coroner. That is an important point. I want to ask the Secretary of State again: will he ensure that achieving the highest standard of complaints handling is included in the next NHS mandate?

No one has done more than the right hon. Lady to try to improve the standard for complaints, with the excellent work she did with Professor Tricia Hart. We are in the process of implementing her recommendations, but as the right hon. Lady knows, with the fifth largest organisation in the world, it is one thing to make a commitment in this place, but another to make it happen on the ground. There is definitely much work to do.

I also agree with the right hon. Lady’s comments about James Titcombe. This is a man who gave up his job working in the nuclear industry to come down to London and work in the CQC so that he could actively be part of the culture change that he wanted to see in the NHS. I do not think anyone could have done more than that. It is truly remarkable.

As the right hon. Lady has mentioned Wales, let me say that we have put 20 trusts into special measures in England and it is inconceivable that there will not be trusts with similar problems in Wales. I urge her to encourage the Labour party in Wales to look at introducing a special measures regime and a chief inspector of hospitals in Wales, because that has had such a powerful effect on improving standards of care in England.

I thank my right hon. Friend for his statement and Dr Bill Kirkup for his excellent report. Let me reassure him and the House that the Public Administration Committee is also preoccupied with the failings of the parliamentary and health service ombudsman in the conduct of these cases. I, too, have met James Titcombe on many occasions and have been extremely impressed by his extraordinary commitment to making sure that he is heard so that so many others can be heard.

May I also point out that the report reeks of the confusion that exists between CQC and the PHSO about what their respective responsibilities are? If we are talking about accountability, what we need is an organisation that is accountable for investigating clinical incidents in the NHS, whether they are down to particular local problems or broader systemic problems—by which we mean not that that is an excuse for what goes wrong; rather, it is so those systemic problems can be put right. I therefore very much welcome what my right hon. Friend has mooted will be the task of Sir Mike Durkin: to look at how that capacity can be developed, in the same manner, perhaps, as the air accidents investigation branch of the Department for Transport.

Dr Mike Durkin will be delighted that he has been promoted and given a knighthood for his wonderful work on patient safety, but it has not happened yet, even though he certainly deserves it. I thank my hon. Friend for his understanding of the complexity of these issues and the importance of the need for culture change. The work of his Committee has not been to scratch around the surface; it has tried to think hard about the solution. He is absolutely right that we need to end regulatory confusion. We now have a strong CQC, which is doing incredible inspections and is trusted across the system. However, we need a system in which people can get independent external advice quickly, which is why he was right to alert me to the potential of an air accidents investigation branch equivalent. I hope that is something that could be helpful for the ombudsman as well.

I am pleased that the Secretary of State has declared his intention to implement the medical examination review. The president of the Royal College of Pathologists, Dr Suzy Lishman, has said that introducing such a system would

“improve patient care whilst reducing harm and saving money”.

She went on:

“If bereaved relatives get the answers that they need around the time of death, if all their questions are answered then, then they don’t feel the need to sue the NHS to get the answers they deserve.”

She has also said that it is “incomprehensible” that the recommended changes have not been implemented. Will the Secretary of State explain why there has been so much delay? From his answer to a previous question, I understand that he is not able to commit to implementing the reforms during the time of this Government.

With the greatest respect, I say to the hon. Lady that if she is suggesting that we have done nothing on this important issue over the last few years, nothing could be further from the truth. We have been trialling the right system; we think the trials have worked; and we want to make sure that we implement this in a way that is consistent with the many other things we are doing to improve patient safety, including proper case-note reviews of deaths in order to understand the level of avoidable hospital deaths and what we can do to bring the rates down. This is a priority for the Government, and we remain wholly committed to it.