With permission, Mr Speaker, I would like to make a statement on the Ockenden report. The independent review was set up in 2017 in response to concerns from bereaved families about maternity care at Shrewsbury and Telford Hospital NHS Trust. Its original scope was to cover the cases of 23 families, but since it began, sadly, many more families have reported concerns. Due to this tragically high number of cases and the importance of this work to patient safety, early conclusions were published in an initial report in December 2020. We accepted all the recommendations of the first report, and the NHS is now taking them forward.

Today, the second and final report has been published. This is the one of the largest inquiries relating to a single service in the history of the NHS. It looks at the experiences of almost 1,500 families from 2000 to 2019. I would like to update the House on the findings of the report, and will then turn to the actions that we are taking as a result of it.

The report paints a tragic and harrowing picture of repeated failures in care over two decades, which led to unimaginable trauma for so many people. For these families, their experience of maternity care, rather than being of moments of joy and happiness, was one of tragedy and distress. The effects of these failures were felt across families, communities and generations. The cases in the report are stark and deeply upsetting. In 12 cases where a mother died, the report concludes that in three quarters of them, the care could have been “significantly improved”. It also examined 44 cases of HIE—hypoxic ischaemic encephalopathy—a brain injury caused by oxygen deprivation. Two thirds of the cases featured “significant and major concerns” about the care provided to the mother. The reports also states that of almost 500 cases of stillbirth, one in four was found to give rise to major concerns about maternity care that, if managed appropriately, “might or would” have resulted in a different outcome.

When I met Donna Ockenden last week, she told me about basic oversights at every level of patient care, including in one case where important clinical information was kept on Post-it notes, which were swept into the bin by cleaners, with tragic consequences for a newborn baby and her family. In addition, there were repeated cases where the trust failed to undertake serious incident investigations; and where investigations did take place, they did not follow the standards that would have been expected.

Those persistent failings continued until as late as 2019, and multiple opportunities to address them were ignored, including by the trust board accountable for these services. Reviews from external bodies failed to identify the substandard care that was taking place, and some of the findings gave false reassurances about maternity services at the trust. The Care Quality Commission rated maternity services inadequate for safety only in 2018, which is unacceptable given the huge deficiencies in care that are outlined in the report.

The report also highlights serious issues with the culture in the trust. For instance, two thirds of staff who were surveyed reported that they had witnessed cases of bullying, and some staff members withdrew their co-operation on the report within weeks of publication. The first report has already concluded that

“there was a culture within the Trust to keep Caesarean rates low because this was perceived as the essence of good maternity care”.

Today’s report adds:

“many women thought any deviation from normality meant a Caesarean section was needed and this was then denied to them by the Trust”.

It is right that both the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives have said recently that they regret their campaign for so-called normal births. It is vital, across maternity services, that we focus on safe and personalised care, in which the voice of the mother is heard throughout.

The report shows a systemic failure to listen to the families affected, many of whom had been doggedly and persistently raising issues over several years. One mother said that she felt like a

“lone voice in the wind”.

Bereaved families told the report that they were treated in a way that lacked sensitivity and empathy. Appallingly, in some cases, the trust blamed the mothers for the trauma that they had been through. In the words of Donna Ockenden, the trust

“failed to investigate, failed to learn and failed to improve”.

We entrust the NHS with our care, often when we are at our most vulnerable. In return, we expect the highest standards. I have seen in my family the brilliant care that NHS maternity services can offer, but when those standards are not met, we must act firmly, and the failures of care and compassion set out in the report have absolutely no place in the NHS.

To all the families who have suffered so greatly: I am sorry. The report clearly shows that you were failed by a service that was there to help you and your loved ones to bring life into this world. We will make the changes that the report says are needed, at both a local and national level.

I know that hon. Members and the families who have suffered would want reassurances that the individuals who are responsible for these serious and repeated failures will be held to account. I am sure that the House will understand that it is not appropriate for me to name individuals at this stage. However, I reassure hon. Members that a number of people who were working at the trust at the time of the incidents have been suspended or struck off from their professional register, and members of senior management have been removed from their posts. There is also an active police investigation, Operation Lincoln, which is looking at around 600 cases. Given that this is a live investigation, I am sure that hon. Members will recognise that I am not able to comment further on that.

Today’s report recognises that since the initial report was published in 2020, we have taken important steps to improve maternity care. That includes providing £95 million for maternity services across England to boost the maternity workforce and to fund programmes for training, development and leadership. The second report makes a series of further recommendations. It contains 66 for the local trust, 15 for the wider NHS and three for me as Secretary of State. The local trust, NHS England and the Department of Health and Social Care will accept all 84 recommendations.

Earlier today, I spoke to the chief executive of the trust, who was not in post during the period examined in the report. I made it clear how seriously I take this report and the failures that were uncovered, and I reinforced the message that the recommendations must be acted on promptly, but as the report identifies, there are also wider lessons that must be learned, and it sets out a series of actions that should be considered by all trusts that provide maternity services. I have asked NHS England to write to all of those trusts, instructing them to assess themselves against these actions, and NHS England will set out a renewed delivery plan that reflects those recommendations.

I am also taking forward the specific recommendations that Donna Ockenden has asked me to. The first is on the need to further expand the maternity workforce. Just a few days ago, the NHS announced a £127 million funding boost for maternity services across England. That will bolster the maternity workforce even further, and fund programmes to strengthen leadership, retention and capital for neonatal maternity care.

Secondly, we will take forward the recommendation to create a working group, independent of the maternity transformation programme, with joint leadership from the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists.

Finally, Donna Ockenden said that she endorses the proposals that I announced in January to create a special health authority to continue the maternity investigation programme that is run by the Healthcare Safety Investigation Branch. Again, we will take her proposals forward, and the SHA will start its work from April next year.

I thank Donna Ockenden and her whole team for the forensic and compassionate approach that she has taken throughout this distressing inquiry. The report has given a voice at last to those families who were ignored and so grievously wronged, and it provides a valuable blueprint for safe maternity care in this country for years to come.

Finally, I pay tribute to the families whose tireless advocacy was instrumental to the review being set up in the first place. I cannot imagine how difficult it must have been for them to come forward and tell their stories, and the report is a testament to the courage and fortitude that they have shown in the most harrowing of circumstances.

This report is a devastating account of bedrooms that are empty, families that are bereft and loved ones taken before their time. We will act swiftly, so that no families have to go through the same pain in the future. I commend this statement to the House.

The Secretary of State is quite right that this is a very important statement, so I will offer the shadow Minister, Feryal Clark, six minutes.

Thank you, Mr Speaker, and I thank the Secretary of State for advance sight of his statement. I am pleased to respond today, not just as the shadow Minister for patient safety, but as a woman and a new mother. I thank Donna Ockenden and her team for the report. I also thank the families who have come forward; we would not be here today without the persistence and resilience that they have shown for more than 20 years in their fight for justice.

Today marks an important milestone for hundreds of families who have been seeking justice. The Ockenden report lays bare the harrowing truth of what those families had to face and why their fight for justice has been such a fierce one: cries for help going unheard; parents having to try to resuscitate their children because there was no one there to help; and women and babies dying needlessly because they simply were not listened to.

The fact that women were silenced and ignored at their most vulnerable, when they were relying on the NHS to keep them safe, is shameful. No woman should have to face not knowing, when she goes into hospital to give birth, whether she and her baby will come out alive. These were not one-off or isolated incidents of negligence. This was the institutional failure of a system that failed to take up many opportunities to realise that it had a serious problem. We are where we are today because of the persistence and resilience of those families and their refusal to give up the fight to expose those failings. The only comfort we can offer them is that their voices have been heard, and that we are committing today, across this House, to ensuring that those failings are never repeated.

For far too long, patient safety issues and the voices of women have been an afterthought in health; that has led to the kind of crises that we saw in Shrewsbury. This needs to change. Patient safety must be a priority for health professionals and Ministers, so I welcome the fact that the Secretary of State has today committed in full to ensuring that the local actions for learning are taken by Shrewsbury and Telford Hospital NHS Trust, and to all the immediate and essential actions in the wider system that are recommended. Will the Secretary of State come to the House later this year to update us on the progress of those actions? The report makes it clear that a safe service cannot be run without a culture of transparency and accountability, so will he set out how he intends to ensure an open culture in the health service with a willingness to learn within maternity services and identify future failings far more quickly?

Underpinning issues in maternity care, as is the case across so much of our NHS, is workforce. Only 10 months ago, as a first-time mother, I experienced just how stretched to the limit maternity services are. 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 staff were not available to care for them. What is the Secretary of State doing to ensure that the NHS recruits the midwives it needs? What is he doing 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 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 own and their babies’ lives in the hands of the NHS want.

I thank the hon. Lady for her remarks. It is not often that we get to say this in this Chamber, but I agree wholeheartedly with what she has just shared with the House. She is absolutely right to talk about this as a fight for justice and to say that if these brave families had not been so persistent in coming forward with what was done to them and what went wrong, the inquiry might never have happened. She is also right to talk about institutional failure at the trust, which the first report set out in some detail and which we are seeing in much more detail today.

The hon. Lady talked, rightly, about patient safety. She will know that the Government have already set out plans to appoint a patient safety commissioner; that appointment will be made soon, but we need to do much, much more. That is why it was right to accept all the interim report’s recommendations, including seven immediate and essential actions and 27 local actions. I can tell the House that the trust has implemented all the actions set out in the interim report; that was backed at the time by £95 million in extra funding. As I said a moment ago, the final report quite rightly makes many more recommendations, which have all been accepted and which are backed by funding of at least £127 million, much of which will go to workforce.

The hon. Lady is right about the need to increase the size of the workforce, especially with respect to midwives. Last year’s acceptance figures for student nurses and midwives were, I think, the highest that the country had seen in decades, but clearly there is much more to do.

We now come to the Chair of the Health and Social Care Committee.

Today’s report goes beyond my darkest fears. When I commissioned it as Health Secretary in 2016, I was approached by 23 families; we have heard today that more than 200 babies might have been alive today if better care had been provided. I thank Donna Ockenden and her team for an incredibly thorough investigation. I also thank the Health Secretary for his compassionate and comprehensive response to the House today.

Donna Ockenden does not use the word “recommendation”; she talks about immediate and essential actions. What is the Secretary of State’s deadline for the implementation of those actions? That is something that every expectant mother in the country desperately wants to know.

May I gently say to the Secretary of State that while I warmly welcome more midwives and more doctors, that approach is not consistent with voting down today the Lords amendment to the Health and Care Bill that would make sure that we never have those shortages again?

Finally, I pay tribute to Richard Stanton and Rhiannon Davies and to Kayleigh and Colin Griffiths. Richard and Rhiannon came to talk to me about their daughter Kate, who died in 2009; Colin and Kayleigh’s daughter Pippa died in 2016, when I was Health Secretary. Because of the blame culture and the culture of fear in the NHS, it was left to them and many other families to fight for justice. Can this be the last time that we put that burden on the shoulders of bereaved families? Can we build a culture in the NHS that is open and transparent and that accepts that things go wrong, but is hungry to learn from mistakes so that we never again repeat the tragedies?

I very much agree. I want to acknowledge that the report ultimately took place because of my right hon. Friend’s decision to ask Donna Ockenden to do the independent review, but he is absolutely right that he, in turn, did so because of the bravery of Rhiannon Davies and Richard Stanton, of Kayleigh and Colin Griffiths and of the many other families who came to see him.

My right hon. Friend asked about the immediate and essential actions. The interim report sets out seven such actions; the trust has implemented them all, and across the NHS they are either fully or partially implemented. The final report also recommends such actions; their implementation has already begun. Of course, we have just received the report, but I have asked for a timetable of when it will all be done. I want to see it done as quickly as possible.

My right hon. Friend’s point about workforce is very important. I hope he welcomes the fact that, for the first time, the NHS has been asked to set out a 15-year workforce plan.

I join colleagues across the House in thanking all the families who have bravely come forward to share their experiences, particularly Kayleigh, Colin, Rhiannon and Richard, whose persistence has led to the review. I hope that women and babies in Shropshire, Telford and the Wrekin and across the UK will be safer in future as a result of their bravery.

I thank Donna Ockenden and her team for their thoroughness in reviewing so many tragic cases. I am sure that the Secretary of State agrees that this can never be allowed to happen again and that the deaths of these 201 babies must not be in vain. This must be a turning point for maternity services in England.

Donna Ockenden has endorsed the findings of the Health and Social Care Committee and recommended that an immediate investment of £200 million to £350 million per annum is required to keep women safe. I welcome the Secretary of State’s guarantees that the immediate and essential actions will be implemented, but may I ask whether he can commit the additional resources recommended by Donna Ockenden today?

I thank the hon. Lady for her comments. I assure her that constituents throughout Shropshire, Telford and the Wrekin, and indeed families across England, will be safer as a result of those brave families coming forward and this report.

On resources, the hon. Lady will have heard me talk about the £95 million given at the time of the interim report, plus the £127 million given for maternity services in the past few days. We will keep that under review.

I thank the Secretary of State for his very welcome statement and the Under-Secretary of State, my hon. Friend the Member for Lewes (Maria Caulfield), for her excellent work. I pay tribute to my right hon. Friend the Member for South West Surrey (Jeremy Hunt) for everything that he has done for patient safety; he has led the way, and I am so grateful.

Does the Secretary of State believe that what we have seen at Shrewsbury and Telford Hospital NHS Trust is indicative of a culture in which senior management were unaccountable, no one felt responsible, failings were minimised, poor care was normalised and women’s voices were not heard? Will he do everything he can to increase the accountability of senior management across the NHS so that that institutional blindness can never again cause such harm to those who put their trust in the NHS?

Let me first thank my hon. Friend for her approach and her role in helping to make the report happen, and for the way in which she has worked with me, and with Ministers in my Department, on this most important of issues. She is right to talk about the importance of culture, especially given that, as the report makes clear, the voices of women were not heard time and again. I want to reassure her that we will implement all the report’s recommendations, but, more broadly, that women’s voices will be at the heart of the upcoming women’s health strategy.

Today is an important day for maternity safety, and we rightly pay tribute to the families directly affected, so many of whom have given evidence to the Ockenden review.

James Titcombe, who lost his baby son Joshua during the Morecambe Bay maternity scandal, has said that one of the most harmful experiences for the Morecambe Bay families was

“seeing influential people in the maternity world diminish… the…findings”

of the investigation report. I join James Titcombe in saying that we must not allow that to happen with this report. I urge the Secretary of State to ensure that the bereaved families are allowed a process of truth, reconciliation and healing, rather than any denial of the truth of what took place.

I agree with the hon. Lady, and she is right to raise the importance of the Morecambe Bay investigation. That report, which I believe was completed in 2015, contained 44 recommendations. Eighteen recommendations that were specifically for the trust have been implemented, and the 26 for the wider NHS are in the course of being implemented.

I thank my right hon. Friend for both the tone and the substance of his response to this devastating report. Let me also add my voice to the consensus throughout the House that the way in which this is handled is vital, and that we must ensure that the NHS takes Donna Ockenden’s recommendations on board. She and her team of more than 90 experienced clinicians are properly being thanked for the work that they have done. They have painstakingly reviewed these cases going back some 20 years, which must have been harrowing for them, as of course it has been for all the families so tragically affected who have had to relive their tragedy.

In particular, I want to praise the courage and tenacity of Rhiannon Davies and Richard Stanton, who were my constituents when they lost their baby Kate in truly awful, and tragically avoidable, circumstances. It was they who kept pressing for answers from Shrewsbury and Telford Hospital NHS Trust. That led me to take them to see the then Health Secretary, my right hon. Friend the Member for South West Surrey (Jeremy Hunt), who agreed to launch this review five years ago. They are no longer my constituents, and I understand that they are now understandably keen to focus their attention on their family, having been living with this trauma since 2009.

I have some questions for my right hon. Friend the Secretary of State. Does he recognise that the Ockenden review has raised fundamental questions for maternity services across the NHS over the culture of so-called normal birth, and that a focus on targets, under successive Governments, rather than on patient outcomes, can distort clinical best practice and, tragically, patient safety? Following his discussion with the trust’s current chief executive, which he has mentioned, is he satisfied that the current management and clinical teams have accepted the “local actions for learning” recommendations in the initial Ockenden report, and are committed to studying and rapidly implementing all further recommendations specific to the trust? Finally, what reassurance can he give the thousands of expectant mothers in Shropshire, Telford and Wrekin that the maternity services there are safe, and that patient safety is paramount?

I thank my right hon. Friend for the way in which he has worked with the Department and with my predecessor in representing his constituents throughout this investigation. He referred to “so-called normal birth” in his question, and he was right to do so: the only normal birth is a safe birth, which is what the NHS should be working towards, but that did not happen in this trust. The report has made that absolutely clear. Just as important are its recommendations, including some for my right hon. Friend’s local NHS trust. I can reassure him—partly as a result of my conversation earlier today with the current chief executive—that all the recommendations in the interim report have been implemented by his local trust, and all those in this report have been accepted.

Let me start by paying tribute to all the families affected, and thanking Donna Ockenden and her team for their recommendations.

More midwives are leaving the profession than are joining it. We cannot run equally safe services in all NHS trusts without appropriate staffing levels. I therefore hope that the Secretary of State will be able to give further details of what the Government are doing to ensure that there are safe staffing levels in all trusts to provide care for pregnant women.

The hon. Lady is right to talk about the importance of having the right workforce, and certainly more midwives. I can tell her than last year there were 30,185 acceptances for nursing and midwifery courses, the highest number in a decade. Recruitment is being supported by some of the extra funding that I have talked about today. The Government have established grants enabling students to take courses, and, where appropriate, are also focusing on international recruitment.

This courageous report makes clear that keeping caesarean section rates artificially low contributed to babies dying. I am pleased that, following a recommendation from the cross-party Health and Social Care Committee, NHS trusts are no longer being assessed on performance for their caesarean rates, but will the Secretary of State go further? Will he ensure that we look at where caesarean section rates remain artificially low in trusts, so that this dangerous “normal births” ideology is eradicated from the NHS once and for all?

The answer is yes.

I, too, pay tribute to the families named in what is a truly shocking report.

I am sorry, but I have not read all the recommendations, so may I ask the Secretary of State whether, as well as identifying issues relating to the culture in this particular trust, the report includes recommendations concerning governance for boards? Boards have a key role in holding their executives to account. Will he be writing to them to make them aware of their responsibilities in that regard? May I also ask him what the implications are for the national clinical audit of the confidential inquiries into maternal and infant deaths?

If I may, I will write to the hon. Lady about the national clinical audit. As for her important point about boards, the report refers to their importance and the importance of ensuring that the people on them are vetted, understand their responsibilities, and have the information that they need in order to fulfil those responsibilities. In, I think, 2014 or thereabouts, the Care Quality Commission changed the rules relating to NHS trust board members, requiring them to meet a new “fit and proper” test.

It is impossible to think about these lost babies, lost lives, and damaged families without becoming very upset and then very, very angry. However, I know from the work I have been doing with midwives and families, mums and dads, in the last six months or so that this does not involve just one trust. We have thousands of midwives marching on the streets. During the pandemic, mums were taking to social media, feeling that they were being marginalised and their voices were not being heard. Midwives tell me that they did not want to speak out before because they did not want to frighten the mums and dads in their charge, and that is why they often feel that they are not heard themselves. So we have to help them. How will the NHS and the Government reassure pregnant women and help the midwives to reassure them, given that all this is in the news at the moment, and how can we prevent other maternity services from failing?

My hon. Friend has raised a very important point. Hundreds of thousands of births are delivered through the NHS each year, and the vast majority are completely safe, as I myself have found and as many other Members have found, including my hon. Friend. What we have heard about today is what happens when it goes wrong, and goes tragically wrong, but especially when that was avoidable.

My hon. Friend was right to talk about the importance of considering other trusts. This report focuses on one trust, but we know that there was a problem in Morecambe Bay and that an independent investigation is taking place in East Kent. There is action to be taken by all trusts. That is why I think it is so important for the NHS to act on the recommendations for the wider NHS, and for me to act on the recommendations for my Department. We will certainly be taking action and so will the NHS.

I thank the Secretary of State for his statement. Not one person could help but be moved by that account or by his sincerity in dealing with this horrific situation. I also want to commend all those involved in the Ockenden report for their work on this issue. Our hearts break for the little babies, the mums and dads and the family units who have been impacted by these horrendous practices, and today we remember and commend the bravery of the families who had the courage to speak out. Given the findings and the negative cloud that will hang over all those who work in maternity services, will the Secretary of State take this opportunity to thank the maternity teams throughout this United Kingdom who, day in and day out, bring new life into this world in a compassionate and professional manner? I am thinking of the wonderful services at Craigavon Area Hospital in my own constituency. I know that those who work there will be saddened today by what they are hearing in the report, so I trust that the Secretary of State can commend them for the work that they do.

I join the hon. Lady in warmly thanking and commending the work of maternity teams throughout the United Kingdom for what they do, day in and day out, especially over the last two years of the pandemic, which has probably made it even harder than normal. I know that they will all welcome this report because they will want to see the very changes that are set out in it.

I would also like to thank the families for shining a spotlight on this. One of my children suffered from oxygen deprivation at birth, through what I now know were failings in my care. I was lucky, though, in my third pregnancy. By sheer fluke, the GP practice I was registered with had a wonderful community midwife. She was with me through my pregnancy and through the birth of my daughter and she took care of me afterwards. I was listened to, I was supported and I felt safe. I thank my right hon. Friend for taking on board these recommendations, but would he agree that every woman deserves that continuity of care? It can make a profound difference in outcomes for families, because they will have somebody by their side who understands them and they will not have to go through their medical history over and over again, often missing out vital pieces. We should have loftier ambitions. Will my right hon. Friend try to make sure that every woman has the opportunity to have their own midwife with them all the way?

Yes, I agree very much with my hon. Friend and I thank her for sharing with the House her own valuable experiences. She is right to talk about the importance of continuity of care, and that is part of our maternity transformation plan.

I thank the Secretary of State for the report, although it is sad that we have to have a report such as this in front of the House. I want to highlight a point and check whether we can do something about it. There are many good people working in our NHS, and the majority of people are probably there for the right reasons, but, unfortunately, due to the culture of institutional blindness that has been mentioned, or to bullying, they cannot whistleblow, and whistleblowers are not being protected. As a consequence, more and more of these types of reports are going to be required, not only on maternity services, because whistleblowers are being targeted and put down. I would ask that whistleblowers be protected and given the opportunity to have their concerns understood and heard.

The hon. Gentleman is absolutely right. One of the reasons we are creating the special health authority that I referred to earlier is to provide that independence, and also more protection for members of staff to come forward. For example, members of staff will be able for the first time to report things they are concerned about directly to the SHA, and it will have the right to investigate.

Many members from across the House have mentioned the incredible bravery of all the parents who fought for their babies, particularly Rhiannon Davies. Rhiannon is originally from mid-Wales, although she now lives in a constituency across the border. There are many women who live in mid-Wales who need to access the Shrewsbury and Telford Hospital NHS Trust, and I am concerned that they will hear about today’s report and be worried about the care that they will be receiving over the next few days. So, as well as implementing the Ockenden review in full, will the Secretary of State please give his reassurance to those women in Wales who need to travel across the border for maternity services?

Yes, I can give my hon. Friend that reassurance. I can add that Donna Ockenden, in doing her work, looked at cases from Wales as well. The issue that my hon. Friend has raised has also been raised by my hon. Friend the Member for Montgomeryshire (Craig Williams), and I can give them both that assurance.

I thank the Secretary of State for his statement, for the obvious compassion that he has for all those involved, and for his support of the Ockenden report. I want to place on record my sympathy with all those parents who still grieve their loss, and for whom no report will never, ever soothe the pain. Will the Secretary of State confirm that the report into this dreadful spate of deaths will be made available to all hospital trusts across the United Kingdom, including Northern Ireland, to ensure that lessons are learned and that the 84 recommendations of the Ockenden report and any mechanisms of prevention can be understood and put in place UK-wide?

Yes, I can give the hon. Gentleman that assurance. We are more than happy to reach out to the Northern Ireland health service and to work proactively with it on improving maternity services in Northern Ireland.

I thank my right hon. Friend for his statement, and all the many Members present who have contributed to the process that has led to this report. Following the remarks by my hon. Friend the Member for Brecon and Radnorshire (Fay Jones), I have been working with my hon. Friend the Member for Montgomeryshire (Craig Williams), who sadly cannot be here today as he has important constituent business, to look at the cross-border nature of this inquiry in relation to his constituency, my constituency of Clwyd South, my hon. Friend’s constituency of Brecon and Radnorshire and others on the Welsh borders. Will my right hon. Friend reflect on the fact that there will be many concerned residents in Wales, alongside the victims outlined in this report, who need representation on this important issue?

Yes, I can give my hon. Friend, and my hon. Friend the Member for Montgomeryshire, who cannot be with us today, the reassurance that they seek.

My right hon. Friend said in his statement that the Care Quality Commission rated these maternity services inadequate for safety only in 2018, which is unacceptable. Can he assure the House that the CQC inspections are now rigorous enough that failings are picked up much earlier to prevent this type of thing from happening again?

I can assure my hon. Friend that there have already been a number of changes in the CQC’s approach, but I cannot give an assurance that it has changed enough, because this report has only just been published and it is important to me to follow through and ensure that, where relevant, the independent regulators are also making the changes set out in the report. To respond to an earlier question from the hon. Member for Enfield North (Feryal Clark), she was right to suggest that there should be an update from Ministers on progress following this report, and I will ensure that that happens. That picks up on this question about the CQC as well.

This House is united in our heartache over the lives lost and the lives destroyed, and over the women who were silenced and told that birthing had happened for centuries so they should shut up, or that it should happen as though in some sort of movie. I am afraid that, as an MP, I have concluded that NHS bureaucracy has a systemic problem of sexism, and I ask the Secretary of State to keep an eye on this nationally. I remember, after 36 hours of labour, being rushed to the operating theatre and being denied a C-section, then being rushed back an hour later and having a C-section, but only because my husband had noticed that my son’s heart rate had plummeted to almost non-existent. We must also prevent the unforgivable and unscientific locking out of loved ones across all health services. It compromises care and it is still happening in hospitals around the country across different types of care.

I thank my hon. Friend for saying what she has said in the way that she did, and also for talking about her own experience. She is absolutely right to emphasise the point that the NHS is there to care for anyone regardless of their gender, but when it comes to women in particular, I hope she agrees that this is precisely why the Government are right to want to set out—as we will do shortly and for the first time ever—a detailed women’s health strategy.

Today I am publishing the root and branch review of the parole system, and copies have been deposited in the Library.

I start by paying tribute to the chief executive officer and the chair of the Parole Board for England and Wales, Martin Jones and Caroline Corby, and to all the staff who work so tirelessly to discharge their important responsibilities. They are dedicated and committed public servants.

Before I address the detail of the statement, and with your forbearance, Madam Deputy Speaker, I will update the House on this morning’s news. In the light of the Parole Board’s direction to release Tracey Connelly, and having carefully read the decision, I have decided to apply to the Parole Board seeking its reconsideration.

More generally, the role of the Parole Board in deciding on the appropriateness of releasing a criminal offender from prison, including many convicted of very serious violent and sexual offences, is clearly of paramount importance to protecting the public and to maintaining and sustaining public confidence in our justice system. It is the first duty of Government to protect the public.

In recent years, a number of decisions to release offenders who committed heinous crimes have led to disquiet, concern and, regrettably, an erosion of public confidence. Take the case of John Worboys, who is serving a discretionary life sentence for rape and other sexual offences. The Parole Board’s decision in January 2018 to release him on licence caused deep concern among his victims and the wider public. It was subject to a successful legal challenge, after which the Crown Prosecution Service successfully prosecuted him for attacking four further women.

I know that hon. Members on both sides of the House have raised the case of Colin Pitchfork, who was convicted of the rape and murder of Lynda Mann and Dawn Ashworth. The Parole Board decided to release Pitchfork in 2021, and it rejected the challenge by the then Justice Secretary, my right hon. and learned Friend the Member for South Swindon (Sir Robert Buckland). The understandable public anxiety was further compounded when Pitchfork was recalled to prison just two months after release for approaching women in breach of his licence conditions.

I make a broader point that in these kinds of cases, and in many others that do not attract the same level of media attention or public interest, victims feel their trauma and raw fear are neither recognised nor understood. Likewise, the public inevitably begin to question the reliability of decision making when serious offenders are recalled to prison for breaches of their licence or for committing further offences on release.

To give the House a sense of scale, in 2020-21 the Parole Board’s annual report stated that 27 offenders went on to be charged with a serious further offence following release directed by the Parole Board panel. There were 40 cases of serious further offences being charged in each of the preceding two years. Placed in context, it is fair to say this is only a fraction of all cases, but more than once a fortnight an offender goes on to commit a serious offence while subject to supervision.

At present, victims who wish to challenge a decision by the Parole Board to release a prisoner have the option of asking the Justice Secretary to apply for the decision to be reconsidered, which is an important innovation that I exercised today for a person convicted in the harrowing case of Baby P. There have been 39 interventions since the challenge mechanism was set up two years ago, with four leading to a change in the release decision.

Following the review published today, I believe the case for reform is clear and made out. In arriving at this conclusion, it is worth pausing to acknowledge the shift in the Parole Board’s approach over time. The statutory test was established in 1991 and states

“The Parole Board must not give a direction”—

for release—

“unless the Board is satisfied that it is no longer necessary for the protection of the public that the person should be confined.”

It is clear from this that the overriding test focuses on public protection. However, in the absence of further guidance from Parliament, the way in which the release test has been interpreted and applied over time has shifted, moving away from Parliament’s original intention. In fact, as early as the Bradley judgment in 1991, the High Court concluded:

“The Parole Board have to carry out a balancing exercise between the legitimate conflicting interests of both prisoner and public.”

To summarise, the statutory test has morphed over time from a strict public protection test to a balancing exercise between, on the one hand, the responsibility of the state to protect the public and, on the other hand, the rights of the prisoner. Whatever the rights and wrongs, that was palpably not the original intention of Parliament.

I make it clear that I am not criticising the courts, which have sought to apply a generic statutory test without more prescriptive guidance from Parliament, nor am I criticising members of the Parole Board, as I hope I have made clear. It is worth saying that, contrary to public perception, it is often fiendishly difficult to come to a reliable assessment of an offender’s risk many years after their original crimes. Although psychiatric assessments and social science can offer guidance, risk assessments in such cases are inherently uncertain and imprecise. We need to be more honest and open about that in our public debate.

In any case, I believe the focus in this critical decision making has become adrift from its original moorings. This Government will again anchor Parole Board decision making on the cardinal principle of public protection. When it comes to assessing the risk to victims and public safety, we will introduce a precautionary principle to reinforce public confidence in the system. In cases involving those who have committed the most serious crimes, we will introduce a ministerial check on release decisions, exercised by the Justice Secretary.

The package of reforms published today will strengthen the focus on public protection at every stage. First, we will revise the statutory test for release and replace the current approach that balances the rights of dangerous offenders against public safety with an overriding focus on public protection, by providing in primary legislation further detailed criteria for the application of the statutory test.

Secondly, we will make sure that the Parole Board is better equipped to make credible and realistic assessments of risk. It is striking that, as of last year, only 5% of all Parole Board panel members come from a law enforcement background. Again, I make no criticism of the current panel members, but that is a significant deficit. I believe the deficit is wrong, and our reforms will ensure that the people we charge with making finely balanced assessments of future risk have greater first-hand operational experience of protecting the public from serious offenders. We will change this imbalance by mandating the Parole Board to recruit more members with operational law enforcement experience, and the Ministry of Justice will run a recruitment campaign to bolster its numbers. Critically, in Parole Board cases involving the top-tier cohort of serious violent and sexual offenders, we will require by law that at least one of the three panel members has a law enforcement background.

The third key reform is that, for the top-tier cohort of high-risk offenders who have committed the most serious offences, we will introduce ministerial oversight of Parole Board decisions to release such offenders back into the community, based on our assessment of the dangerousness of the offender, the risk of serious further offending and public confidence. These top-tier offenders will comprise those serving sentences for murder, rape, terrorism and causing or allowing the death of a child. In those cases, we will make two specific changes. The Parole Board will be able to refer a case to the Justice Secretary if it cannot confidently conclude whether, on the evidence, the statutory test for release has been met. In addition, we will introduce ministerial oversight over any decision to release any offender in the top-tier cohort of serious offenders. Under our reforms, in that top tier of cases the Justice Secretary will have the power to refuse release, subject to judicial challenge, on very clearly prescribed grounds, in the upper tribunal. I believe that is warranted as an extra check and safeguard to protect the public. I have not yet ruled out entirely an alternative model that could establish a three-person panel chaired by the Justice Secretary with the same power to refuse release, subject to judicial review in the normal way. We will consider further detail of the mechanism in order to strike the most effective balance.

We are making these reforms because the concept of risk is notoriously difficult to assess in these kinds of cases. We are doing it because the public expect their safety to be the overriding consideration and because, ultimately, it involves a judgment call about public protection, and the public expect Ministers to take responsibility for their safety. Let me be equally clear that there is no such thing as a risk-free society; we cannot guarantee that no one released from prison will go on to commit a serious crime. Let us be very clear about that as we have a more honest debate about the assessment of risk. Nevertheless, I believe that these measures are necessary to reinforce public safety and public confidence, and we will legislate for them as soon as possible. I should also say that we will do so alongside our proposed Bill of Rights, to ensure that the will of Parliament and that focus on public protection is not undermined by the Human Rights Act. Indeed, our reforms to parole yet again highlight the compelling case for a Bill of Rights.

Our fourth reform will increase victim participation in parole hearings, thereby delivering on this Government’s manifesto commitment. I recognise that parole decisions will be immensely and acutely traumatic moments for many victims, as they are forced to remember, go through and revisit the ordeal and suffering that they have already been though. Some will not wish to be involved, whereas others will want their voices to be heard, and I believe they should have that right. So we will give victims the right to attend a parole hearing in full, for the first time, should they wish to do so. In addition, we will require the board to take into account submissions made by victims and allow victims to ask questions through those submissions. The voice of victims will be at the centre of the process, not just some lingering afterthought.

Finally, although separate from parole decision making, similar considerations of risk and public concern have arisen in the context of decisions to transfer prisoners to prisons in open conditions. That is why in December 2021 I changed the process to introduce a ministerial check on such decisions, guided by similar principles to those that I have already set out. That is what led to my decision this month to reject the Parole Board’s recommendation to move Steven Ling, who raped and killed a woman, to an open prison. I declined the move in the interest of public protection and public confidence.

In sum, our reforms will ensure that those offenders who present the highest risk to public safety are reviewed more rigorously, with additional ministerial oversight. Protecting the public is the Government’s top priority. The proposals in this review will reinforce public safety. I commend this statement to the House.

I thank the Secretary of State for advance sight of his statement earlier today. It is hugely timely, given the disturbing news about the potential release of Baby P’s killer. I fully support the Secretary of State in seeking a review of that. In broad terms, I welcome his statement too. It is crucial that public protection is paramount and that victims are right at the heart of the criminal justice system. Currently, too many victims feel that their views are not taken sufficiently into account, either in parole decisions or in sentencing, and that leads directly to public safety concerns, which must be taken more seriously. Labour will put public safety at the core of our contract with the British people. Sadly, the same cannot be said of this Government.

It is less than two months since the convicted sex abuser Paul Robson walked out of a low-category open prison in Lincolnshire. After he escaped, the public were warned that Robson was a serious danger to women and children. He clearly should never have been in a low-security prison in the first place. The Parole Board made that recommendation, but it was the Secretary of State who approved it. He or his predecessors already had the necessary powers, they just did not use them. So what will stop him making serious mistakes like that again when he exercises his new check and oversight powers in, potentially, hundreds more cases? Labour wants victims to have the right to make a new personal statement saying how they would feel if the prisoner is released. We would like any assessment of the risk to the public to include the risk of re-traumatising the victim, and to prevent released prisoners from living near their victim if that is against the victim’s wishes. Will the Secretary of State consider those additional proposals?

The appalling decision to release the multiple rapist John Worboys was only stopped after the Centre for Women’s Justice sued the Government, using rights established by the last Labour Government. Sir Peter Gross’s review made sensible proposals to improve these rights, including the UK’s margin of appreciation over interpretations we would all object to. But the Secretary of State will be throwing the baby out with the bathwater if he uses that concern as an excuse to take away British rights that protect British people from dangerous criminals, as they did in that case. Too many victims of crime do not get a say over what happens to criminals because those criminals are never prosecuted in the first place. That is because this Conservative Government cut 21,000 police officers and still have not replaced them, despite imposing the highest rates of personal taxation for 70 years —that is 21,000 people with law enforcement experience that his party sacked, whom he might now approach to sit on parole boards, as he suggests.

The Secretary of State spoke about rape cases in this statement, but only 1.5% of reported rape cases ever make it to court. Those that do now take more than 1,000 days, on average, before the trial starts—these are the longest delays in British legal history. What message does he think that sends about public safety and public protection? Under this Government, prosecution rates for crimes including burglary, robbery, car crime and fraud are so low that they have, in effect, been decriminalised. There are so few police left that victims are told to fill in a form online and hardly any of them ever hear anything again. It is no wonder that the Government stand accused of going soft on these crimes. Does he recognise that letting criminals get away with crime damages public safety and erodes confidence in the justice system, which is something he is telling us this afternoon that he wants to strengthen? The Victims’ Commissioner has called on the Government to establish a new victims’ right to review. That would give victims the power to challenge decisions by the police and the Crown Prosecution Service not to prosecute or to drop prosecutions. The Secretary of State did not mention that in his statement, so will he tell us whether he intends to introduce proposals along those lines in future?

Public protection requires victims to be active participants throughout the criminal justice process, including in parole decisions. Their insights strengthen public safety and public confidence in the system. Today’s statement is a step forward and it recognises some of the Government’s mistakes, but it could have been bigger.

Let me start by thanking the hon. Gentleman for his support for the decision taken today in the Tracey Connelly case. I think he also gave wholesale backing to the reforms I set out in my statement, which is important. I want to welcome what I therefore hope will be cross-party support when we come to legislate for them; he cannot support the aims and then not will the means, and I hope that that becomes clear as we take the proposals through the House.

The hon. Gentleman asked about absconds, which is an issue of significant concern. I should say to him that between 2009-10 and today, the level of absconds from prisons has fallen to a third of the level it was under the last Labour Government. He might want to think a little about that before he makes unfounded assertions.

In fairness, the hon. Gentleman did ask about the case of Shane Farrington, who absconded on 24 March but was rearrested on 26 March. He is ineligible for a return to open conditions for two years. The hon. Gentleman made a point about our being empowered to do something; actually, that took place in October and I changed the rules in December, as I have made clear to the House.

I welcome what the hon. Gentleman said about the role of victims. We are making important changes and I welcome his support for them. I gently point out that, even before the spending review, the level of victims funding was three times the level it was at under the Labour Government. He talks about victims; our record is infinitely better, but we are restless to do far more.

More generally, the history of the reforms we are undertaking took place on Labour’s watch, because in 2008 Labour gave up the power to block the release of prisoners who had been sentenced to more than 15 years and then legislated to make the changes—in fairness, they were forced on that Government by the Human Rights Act—permanent. As a result, the number of those recalled on life licence skyrocketed, going up almost sevenfold. The hon. Gentleman should, then, have a little more humility about where the problem came from.

The hon. Gentleman criticised our approach to the Bill of Rights, but it is clear that we cannot pursue the reforms I have set out and reverse the challenges that were made under the Human Rights Act without our Bill of Rights. Again, the question for the Labour party is going to be whether it just wills the ends or is willing to back the means.

Last month, I picked up my copy of the Daily Mirror, as I do, and read through it. I read that the hon. Gentleman had said that under the previous Labour leader, the right hon. Member for Islington North (Jeremy Corbyn), Labour had appeared to care

“more about criminals than their victims”.

That is a greater measure of humility, but the hon. Gentleman should take a bit of responsibility for his record. He and the shadow Cabinet voted against extra funding for more police officers. They voted against the tougher sentences for dangerous offenders in the Police, Crime, Sentencing and Courts Bill—the kind of thing that would protect victims and the public. I am glad that, on this issue at least, the hon. Gentleman is showing that he is willing to support measures that will stand up for victims and protect the public. The proof of the pudding will be in how the Opposition vote when all the measures come before the House.

The statement was excellent. My right hon. Friend is clearly revelling in an area of policy in which he has a great deal of expertise. One aspect of which I did not hear mention was the concept of punishment. Some offences, particularly the sort we are dealing with in this context, are absolutely heinous. It baffles the public as to why, for example, someone who led a home invasion in the New Forest that resulted in the burning alive of an entire family, although not until after the woman had been repeatedly raped, should be considered for release at the end of what is admittedly a long sentence. Most people would feel that people forfeit their right to liberty when they commit offences of that gravity. Where does punishment fit into all this?

I totally understand the point that my right hon. Friend makes. In truth, parole is about risk and, rightly, public protection. Either the tariff or the overall sentence should deal with the element of punishment, rather than parole. Nevertheless, my right hon. Friend makes an important point. He will know that whether it was Harper’s law, Tony’s law or the wider reforms to sentencing that we are making in the PCSC Bill, we have strengthened sentencing, in the teeth of opposition from Opposition Members.

In fairness, I do need to draw a distinction in respect of the reforms I have set out: they are really about public protection and the amorphous concept of risk in these cases. That itself also goes to the issue of public confidence in relation to the tariff and the punishment element that my right hon. Friend mentioned. Both are important, but with parole we focus on risk. I say that because I want to be clear that we are not adding another sentence on top of a sentence. The question, from the point at which an offender becomes eligible for parole, is whether they satisfy the statutory criteria. Is it safe to release them, or do they present an ongoing risk to public protection? That is the core focus of the reforms I have announced today, but I heed my right hon. Friend’s wider point.

I thank the Secretary of State for his statement and welcome the broad thrust of his recommendations. I notice that the second reform deals with the assessment of risk. The Secretary of State’s proposal is to employ more people with a law and order background, which I am quite happy to accept. I also notice that the report by the charity Justice published in January this year recommended:

“Enhancing the Parole Board’s programme of training to include”—

among other things—

“critical analyses of offending behaviour programmes and risk management tools”.

Does the Secretary of State have any plans to take that recommendation on board?

I thank the hon. Gentleman for his constructive and reasonable question. We will look at everything on training. The truth is that the members of the Parole Board come with a vast depth of experience; my question is whether we have the range right. Psychiatrists and psychologists have a critical role to play, and judges and lawyers inform the process, but if we say that our overriding focus is public protection and we have finely balanced questions of risk in relation to people who have committed a so-called index offence many years previously, I would have thought that, particularly for top-tier cases, the public would want to know that the grizzled police officer, for example, who has seen such cases before and knows the pattern of behaviour is also there to provide that dimension of critical thinking.

The hon. Gentleman is right in what he says about critical thinking. We need to make sure that the Parole Board panels, particularly for the serious, top-tier cohort, have a broad diversity of experience so that we can take a precautionary approach and protect the public.

I thank my right hon. Friend for his statement and continue to be impressed by how he and the Ministry of Justice are gripping so many complex justice matters all at once. This is about not only public safety but the perception of public safety. The public rightly care about law and order. I hear strong words from those on the Opposition Front Bench, but we can see from the lack of turnout among Labour MPs that they prefer to politick on this issue rather than to do the hard graft of scrutiny.

On scrutiny, I really welcome that my right hon. Friend is putting victims at the heart of Parole Board decisions and allowing them input. Will he say a little more about how the Parole Board has taken to those proposals? How can we support victims as they go through that process? Some of them will find those steps distressing even if they want to take them.

I thank my hon. Friend for her tenacity on these issues. She makes the same point as the one my right hon. Friend the Member for New Forest East (Dr Lewis) made about public confidence. There is no escaping that, particularly if we think of the history of parole and licence conditions and of how we ended up with life terms after the abolition of the death penalty. The public need to have confidence that sentences match the crime and that their safety is of paramount importance.

My hon. Friend asked about how we will help victims through the process; that is critical, because it must be gruelling and traumatic for them. I know from the consideration that I have given the matter and from the evidence I have seen how difficult it will be. We have already made some improvements in the process for victims: in 2018, we introduced written decision summaries to improve transparency for victims; in 2019, we introduced the reconsideration mechanism, which I exercised today; and in 2021, we announced our intention to enable public hearings and for victims to be able to attend them as observers, and we are now giving them a much fuller role, as I explained in my statement. On top of that, of course, is the statutory release test. When the Parole Board considers that test, it will take clear account of victims’ submissions and victims will be able to ask questions through their submissions.

I thank the Lord Chancellor for the statement; I am encouraged by the steps he has introduced today to address what one victim said to me was a “reprehensible” parole system. That lady contacted me after the murderer of her son was released and she saw him in the local Tesco. She received no warning that he had been released early. Will the Lord Chancellor confirm that the legislation will include a legal obligation to inform victims and their close family? Will he be in touch with the Minister in the Northern Ireland Assembly to discuss the legislation proposed for this place that can also be introduced in Northern Ireland?

The root and branch review will set out all the victims’ rights in the process. The hon. Gentleman will be able to see that. Copies are now available in the House. Of course we respect the devolved settlements on this, but we are always willing to engage with the devolved Administrations around cross-cutting issues and those of common concern.

The public will rightly expect that their protection is the overriding concern when serious offenders are assessed either for release by the Parole Board or, indeed, for transfer to an open prison, a subject on which my right hon. Friend touched. I know from my own time as non-executive director at Her Majesty’s Prison and Probation Service that open prisons can be an extremely important part of an offenders’ rehabilitation, especially at the end of a very long sentence. We have seen recent cases where the current test has clearly not worked effectively. Does my right hon. Friend agree that time in an open prison should always be regarded as a privilege, certainly never an automatic right? Will he confirm that the measures that he has already introduced, and that he is going on to introduce later today, will result in a more cautious approach that will make sure that the public is always safe?

I agree with everything that my hon. Friend said. I do not think that there is a trade-off. In fact the two things go together: we want to protect the public as well as identify those who can be released into open conditions or into society—those who are ready to play the right role, to reintegrate back into society, to work, to look after their families and to stay clean of drugs. All of those things go together. Ultimately, our objective is to protect the public, drive down crime and reduce reoffending.

I thank my right hon. Friend for his statement and for engaging with me over my one-punch awareness campaign, something about which I am deeply passionate. Victim support is at the very heart of that campaign, because, as we all know, the victims of crime and their families do not stop suffering the moment the crime stops being committed; they can suffer for months, years and even the lifetime that follow. That is why the victims of crime need to be at the very heart of our criminal justice system to ensure that they receive the support, protection and reassurance they need. Can my right hon. Friend confirm that these proposals will improve victim support and public protection, particularly for victims of the most serious crimes?

I pay tribute to my hon. Friend for her tenacious campaign and say that I know how difficult that must be for her. None the less, it is very important, and she brings a huge amount of experience, particularly personal experience, to the Chamber and to the changes that we are making. I agree with what she has said. I have set out for the House the changes that we are making for victims in relation to the parole decision-making process, but they are only one element of a much broader strategy, and we will, of course, be introducing a victims’ law. Again, I hope the whole House can rally around that, so that victims feel that they are front and centre of this, that they are listened to, that they are taken into account, and that they are part of the criminal justice system, not an appendix to it.

When Paul Robson escaped from the North Sea Camp open prison in my constituency, the sudden presence of this violent rapist in the community was deeply traumatic not just for his victims, but for all those people who live in and around the area that the prison occupies. By definition, although the Parole Board does immensely difficult work, the fact that he absconded means that he was in the wrong place. Will my right hon. Friend reassure me that what he has announced today makes it far less likely for a convict such as Paul Robson to be in those conditions and to place the public at risk in the way that he did when he absconded?

I can reassure my hon. Friend on that. The changes that we made in December should give him some reassurance. There is no risk-free approach here. What we do is try to create safeguards to mitigate as best we can while maintaining a free society. I also note that, under successive Conservative Governments, the number of absconds has fallen, from 296 in 2009-10 to 101 in 2020-21—a third of the level. We have the security right, but we will continue to make sure that we reinforce it.

I warmly welcome my right hon. Friend’s statement today. Does he agree that, in those most serious of cases, the public do not expect politicians to throw up their hands and say, “Well, it was a decision for the Parole Board”? They expect them, as the ones accountable for keeping them safe, to step in and do so because it is their No.1 job.