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Maternity Services: East Kent

Volume 671: debated on Thursday 13 February 2020

(Urgent Question): To ask the Secretary of State for Health and Social Care if he will make a statement on the provision and safety of maternity services in East Kent.

I will set out the situation concerning East Kent Hospitals University NHS Foundation Trust in line with the written statement laid in Parliament this morning. In fact, I took steps to inform Parliament of this matter before the UQ was requested, and I hope that reflects the importance I place on this issue. Before I begin, I would like to express my deepest and most heartfelt sympathies for the patients and families who have been affected.

I made a statement on 28 January on concerns about maternity services in East Kent Hospitals University NHS Foundation Trust, and I would now like to update the House based on the reports from the independent Healthcare Safety Investigation Branch and the Care Quality Commission. I requested that both HSIB and the CQC report back to me within 14 days when I instructed them to go into East Kent trust two weeks ago, and they reported to me on Monday.

HSIB has already conducted a number of maternity investigations at the trust as part of its national maternity investigation programme. These identified a number of safety concerns, including the availability of skilled staff—particularly out of hours—access to neonatal resuscitation equipment and the speed with which patients’ concerns are escalated up to senior clinicians and obstetricians, along with failings in leadership and governance.

As requested, the CQC carried out an unannounced inspection of the trust’s maternity services between 22 January and 5 February. It has written to the trust with an oversight of its findings, and the full inspection report will be published in due course. The CQC received additional information from the trust this week, following its request for further assurances on triage, day care and medical staffing. The CQC is considering this information. It is important that everyone is aware that the CQC is in regular contact with the trust and will continue to be so for the foreseeable future.

From the findings provided to me by HSIB and the CQC, it is clear that the challenges at East Kent point to a range of issues, including having the right staff with the right skills in the right place, effective multidisciplinary working, clear collaborative working between midwives and doctors, good communication and effective leadership support, but it would be wrong to speculate that there is indeed one single cause.

NHS England and NHS Improvement are working closely with the trust and have taken some immediate actions. First, the regional director and regional chief nurse are providing support to the trust, and the medical director will address concerns surrounding appropriate senior medical oversight. Secondly, the regional chief nurse is providing support to the director of nursing and head of midwifery, to prioritise and focus their local maternity improvement plans and address identified safety concerns. They will also review the effectiveness of clinical governance and executive leadership support. That will include ensuring that the trust learns from all historical cases, and disseminates that learning throughout the trust.

The Chief Midwifery Officer, Jacqueline Dunkley-Bent, has sent an independent clinical support team to the trust to provide assurances that all possible measures are being taken. That expert team includes a director of midwifery services from an outstanding trust, two consultant obstetricians, and a consultant paediatrician and neonatologist. She has placed the very best at the heart of the trust, on the wards, and at the bedsides of patients, with fresh eyes to oversee the care currently being delivered. The independent team is working with trust staff to deliver immediate improvements to care, and to put in place robust and comprehensive processes to support improvements in standards over the long term. Jacqueline Dunkley-Bent has personally visited the trust to assess the changes being put in place, and to ensure that improvements are moving at pace.

Jenny Hughes, chief midwife for the south-east region, is working with the trust directly, and regional and national teams from NHS England and NHS Improvement will continue to work with the trust. The trust is taking the issue seriously and is working closely with NHS England and NHS Improvement. It has created and filled several specialist midwife posts. Safety huddles, where safety issues are regularly and frequently discussed, have been embedded on both sites to anticipate problems before they occur, and multidisciplinary teams are working collaboratively.

Order. The Minister is supposed to speak for three minutes, but we are now at five minutes plus. I realise that she has been given a lot of notes, and I think officials ought to take on board the time. I am not looking to you, but I am looking to others to help in the future. I am sure we will be coming to the end of the remarks, as there are lots of questions.

Thank you, Mr Speaker. I think in defence of my officials, because this is such a sensitive issue—

Order. I am not getting into a debate about this. I do not make the rules of the House. The House makes the rules, and it has decided that responses should be for three minutes, not me.

I will go straight to my closing statement, Mr Speaker. I reiterate my condolences, particularly to the family of Harry Richford and all those affected. I also thank my right hon. Friend the Member for North Thanet (Sir Roger Gale) for raising this important issue. The Government are fully committed to reducing patient harm and improving the safety of maternity services.

I will try hard not to abuse your generosity, Mr Speaker, and on behalf of Tom and Sarah Richford I thank you for allowing me to ask this desperately sad and desperately urgent question. I also thank the Minister for her swift and robust action since the report landed on her desk on Monday night, which was based largely on her personal professional experience. I am deeply grateful, and I know that the families are too.

This morning, at an early hour, I spoke for half an hour with a husband and wife who now live in Australia. Two months after the death of Harry Richford, they lost their own child under similarly tragic circumstances, and it was the most harrowing call I have taken in 36 years in this House. Those parents deserve and need the opportunity to achieve closure and move forward, and they need to know that the failures in protocol, in clinical judgment, and in management, have been addressed.

Will my hon. Friend publish the Care Quality Commission report to which she referred as soon as possible? Will she seriously consider establishing an independent inquiry, so that at the very least, Harry Richford’s parents, Rosie’s parents, and others, will know that their children have not died in vain, and that this will never, ever, happen again?

I thank my right hon. Friend for his comments and suggestions. In response to his call for an independent inquiry, last night I asked my officials to look into sending the independent Healthcare Safety Investigation Branch back in to do a deep dive into historical and existing cases at the trust. I want to reiterate that the trust is a safe place for any woman who is pregnant or giving birth. We have some of the very best people and clinicians working in that trust right now.

I would just like to add that NHS England and NHS Improvement are themselves commissioning an independent review into East Kent maternity services, so my right hon. Friend’s question has been answered. That is the news I have just been given. We are taking this situation very seriously. We will publish the findings of the HSIB and CQC reports in due course, because we take this matter—I personally take this matter—very seriously.

Our thoughts go out to all the families, including the family of Harry Richford, who have endured unimaginable heartbreak because of avoidable and preventable failings at the trust. Harry Richford was aged just seven days when he died. His death was described by the coroner as “wholly avoidable”. This was a wholly avoidable tragedy and not, as the trust originally said, “expected”. After Harry died, the trust refused to refer the case to the coroner and it was only the persistence of the family that led to the inquiry.

The trust will now receive special support to help turn things around, but can the Minister outline exactly what that support will be, by whom and where the funding is coming from? Why has it taken us so long to get to this point? It was reported earlier this month that despite evidence in a report by the Royal College of Obstetricians and Gynaecologists back in February 2016, the same mistakes were made in subsequent years. We need an explanation for why those warnings four years ago were allowed to go unnoticed and unaddressed. I understand that the trust will not be put into special measures and it seems that the chief executive and the medical director will be staying in post. However, given the trust’s failure to deal with those identified failings at the first opportunity, there must surely be questions about the local leadership. Can the Minister outline whether anyone in the trust will be held personally accountable?

Once again, we are unfortunately hearing about another tragedy where the culture has exacerbated the pain suffered by the family: denial, obfuscation and a staggering lack of transparency. Why is it that these issues only come to light because of the persistence and bravery of the affected families? We need to create a culture within the NHS where safety concerns can be raised by trained staff at all levels, free from fear so that issues are dealt with quickly. Perhaps the biggest concern we have is that we do not know the true number of avoidable maternity deaths at the trust.

I would like to join Harry’s family and other Members in calling for a full independent inquiry. I understand that the HSIB deep dive will address matters to some extent, but I do not think it is the full transparent inquiry that the parents deserve and demand.

I thank the hon. Gentleman for his collaborative tone on this issue. I think he may have missed my last comment, which was that NHS England and NHS Improvement will be commissioning an independent inquiry. That has been decided this morning, so that will happen.

On the hon. Gentleman’s first question about what is happening to support the trust now, NHS Improvement is in there. As I said, the chief midwife, Jacqueline Dunkley-Bent, has sent in some of the best midwives, obstetricians and neonatologists in the country from outstanding trusts to support the trust. They are having twice-daily huddles on the wards, which is where multi- disciplinary teams get together and discuss on an ongoing and regular basis what is happening on the wards, what disciplines are involved and what measures are being taken. We have fresh eyes looking at the cartography that measures foetal heart rates and contractions. We have a second pair of eyes reading those cartography read-outs, so it is not just down to one midwife.

A huge amount of support has gone into the trust. As I said, it is today a safe place for anyone to give birth. We are also asking HSIB to go in to do that deep dive to look at historical issues. Whether that will continue in light of the fact that NHS England is commissioning an independent inquiry is something I need to find out when I leave the Chamber. However, I want to reassure the hon. Gentleman and everybody that this is an issue that I take very, very seriously.

Babies bring joy and happiness when they arrive, and every family—every mother, every father and, indeed, every grandparent—is entitled to know that when they or their relative is in hospital, the delivery will happen in a safe environment, with the very best care. I can say that that is the case at East Kent now, and I—we all—will strive to make sure that it is the case at every hospital.

I thank my right hon. Friend the Member for North Thanet (Sir Roger Gale) for tabling this urgent question and for speaking so powerfully. I also thank the Minister for her work to respond to this. I, for one, hope that she continues in her role after the reshuffle because of her incredible commitment to patient safety.

What worries members of the public is that the NHS appears to be much better at transparency about care failures, but not always much better at learning from those failures. Does the Minister agree that that underlines the vital importance of the independent investigations that HSIB does into every Each Baby Counts incident, and the need for safe spaces so that doctors, nurses and midwives can talk openly and freely about what they think went wrong? Will she also consider publishing the report that CQC has already done into what is happening to reassure families that we are indeed confronting all these difficult issues?

My right hon. Friend is absolutely right. One of the issues in dealing with the ongoing problem—this is a bit like the airline industry—is that we need to generate a culture in which NHS staff feel able to speak up without fear of blame or litigation and we can take learning forward. Another issue is that when we have inquiries, we should take the recommendations and ensure that they are implemented. That piece of work is also going forward, along with HSIB and inquiries. We should look at implementing absolutely everything that we can to make sure that the safest possible environment exists.

I am extremely grateful to the Minister for addressing these urgent issues and to the right hon. Member for North Thanet (Sir Roger Gale) for securing the urgent question, as well as to the former Health Secretary, the right hon. Member for South West Surrey (Jeremy Hunt), who has shown a real interest in this case—especially now that he is Chair of the Health and Social Care Committee. I thank them very much.

I am grateful that we are talking about these inquiries and investigations. So many things have been brought up in the reports, and there are many questions from my constituents, dozens of whom are now really terrified about their future pregnancies and having babies in the area. Will the Minister think about committing to safe staffing levels, because there are so many issues in our trust, and that would be one way to reassure staff and patients?

I thank the hon. Lady for her commitment to working with her constituents, which is shared by my right hon. Friend the Member for North Thanet (Sir Roger Gale) and my hon. Friend the Member for Dover (Mrs Elphicke). I think that we should refrain from using words such as “terrified” because, as I said, the trust is a safe place for any woman to give birth. We have the best midwives, obstetricians and neonatologists from outstanding trusts working there now. She will know, as I do, that the trust’s location is slightly remote. Recruitment outside the major cities is a difficult issue, and we have to look at that for maternity services in trusts that are outlying in geographical terms. She is absolutely right to raise that issue, but I reiterate that it is very important that she lets her constituents know that the trust is a safe and welcoming place for women to go and give birth, because some of the very best staff in the country are working there right now and making sure that that is the case.

I pay tribute to my right hon. Friend the Member for North Thanet (Sir Roger Gale) for his respect and diligence in securing answers for the family of baby Harry Richford, and also the hard work, commitment and compassion that has been shown by the Minister, particularly over the last two weeks, when she has worked night and day to make sure that there is a healthy and safe environment for our constituents—I thank her for that. Such strong and compassionate leadership in the handling of these tragic matters has not been shown by the trust, and I would like assurances that matters of culture, leadership and management will be addressed in the next stage, together with any update on whether inquests will be extended in relation to situations such as baby Tallulah-Rai, when there cannot currently be an inquest?

My hon. Friend was not in her usual place when I referred to her earlier, but now she is! I thank her for her kind comments.

I think that we now need to let the NHS and NHS Improvement go in and do their work, and to have the independent inquiry. As my hon. Friend knows, when an independent inquiry is taking place, these issues become more difficult to talk about, but I am sure that the inquiry will include a full assessment of the executive team and the board at the hospital, because those at the top must take full responsibility for whatever has happened in the trust. I hope that Simon Stevens of NHS England will not mind my saying that no stone will be left unturned. I will certainly be seeking reassurances that that is the case, and, from ward level to the chief executive’s office, this inquiry will be thorough and robust, because I will make sure that it is.

My right hon. Friend the Member for North Thanet (Sir Roger Gale) described powerfully the devastation and grief that these families are going through. Can the Minister reassure us that they are being given support to help them through this really difficult time?

I must congratulate Jacqueline Dunkley-Bent, the Chief Midwifery Officer at NHS Improvement —we are very lucky to have her. Compassion drives her, along with the absolute pursuit of excellent maternity standards. I know that there will be support for those families, and that NHS Improvement will also be reaching out to women who are pregnant and are due to go into the trust.

Let me say this, because I did not mention it in my original response. A number of measures are being taken in relation to the trust, which I probably cannot specify, but a written ministerial statement, which is in the House of Commons Library, gives the full list. I want Members to be reassured that those measures are thorough and robust, and they are working.

I thank the Minister for her excellent work and I hope that she does indeed continue in her present position.

Tragically, East Kent is not just a one-off; there seems to be a more widespread culture of denial throughout the NHS. We have seen that in the trust in my constituency. The management is saying, “It is historic, it is scare- mongering, it is just a few preventable deaths.” Does the Minister agree that if those in hospital management are to learn lessons, it is essential that that culture of denial is tackled and they recognise their shortcomings so that services improve?

As my hon. Friend knows, I have been to Shrewsbury and Telford Hospital NHS Trust to reassure myself—line by line—that every recommendation that was made by the Care Quality Commission has been implemented and is working. I thank her for raising this issue, but I also want to emphasise that Shrewsbury and Telford is a safe place for women to give birth, because the same robust approach is being taken there. It is a safe environment, and, as my hon. Friend will know, a new midwife-led unit will be opening shortly.

However, there is a culture that I know concerns the former Health Secretary, my right hon. Friend the Member for South West Surrey (Jeremy Hunt). In such circumstances, trusts do not feel able to put their arms around parents, to say sorry, to explain to them what has happened, and to show compassion or care. That culture must be broken, and I think that HSIB will go a long way towards contributing to the process.

All too often when a baby dies, the shutters come down in a trust and we cannot get the answers that we need. Will the Minister—who is providing great leadership in this area—meet members of the all-party group on baby loss to discuss how best we can use MBRRACE-UK, HSIB and other investigators to get to the bottom of what happens? Will she also think about making maternal deaths a never event?

I fear that you will shout at me again, Mr Speaker, if I try to answer my hon. Friend’s question fully, because I agree with everything that she has said. Maternal deaths absolutely must become a never event, and we must focus on making pre-eclampsia and post-partum haemorrhage, which lead to such deaths, never events. I went to the first meeting of the APPG on baby loss and, as my hon. Friend knows, I am always happy to go and hear anything that anyone has to say about this issue that will help our work in trying to improve maternity standards[Official Report, 2 March 2020, Vol. 672, c. 4MC.].

I should mention at the start of my question that I work as a consultant paediatrician, and that I look after babies and have attended a number of deliveries. I would like to thank the Minister for being so thorough, robust and dedicated in ensuring that this situation improves and that babies are safely delivered throughout the country. In my practice, I have noticed that all baby deaths and adverse outcomes are thoroughly investigated locally, but in my experience this tends to be done just locally. The lessons might be shared internally, but they are not being shared with other hospitals down the road, where the same mistake might be made. I welcome what she is doing, but can she reassure me that those lessons will be shared nationally, so that everyone can benefit from the lessons that are learned, and that such sharing will be widespread so that future tragedies are prevented? Can she also reassure me that, when she sets up the Healthcare Safety Investigation Branch process, its culture is such that doctors, nurses and midwives are able to give full and free answers, and that we get the balance between accountability and blame just right?

I thank my hon. Friend for her comments as a consultant paediatrician. She is a huge source of advice to me at times, including informally over a cup of tea. On her first question: yes, she is absolutely right to say that the investigations take place at local level and that that goes inwards into the local trust. I think that is something that we have to review. On her question about disseminating learning nationally, that comes through HSIB, but she is right to suggest that HSIB does not go into every investigation. One of the problems with a trust investigating itself and taking the learning inwards is the question of what reassurance we have that lessons are being learned and disseminated, and that improvements are taking place. I am going to ask officials to look at that, because we might have to work on developing a different model for maternity services, although we do have NHS Resolution and the HSIB, and a lot of work is going on in this area. However, we have seen too many cases in too short a space of time, and we now have to look at maternity services and patient safety with fresh eyes and decide how we make this the best for parents who have tragically lost a baby, from that moment onwards until they move forward.