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Ockenden Report

Volume 820: debated on Wednesday 30 March 2022


My Lords, the Statement is as follows:

“Mr Speaker, with permission, I would like to make a statement on the Ockenden report. This 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 from this first report and the NHS is now taking them forward. Today, the second and final report has been published. This is one of the largest inquiries relating to a single service in the history of the NHS, looking at the experiences of almost 1,500 families from 2000 to 2019. I would like to update the House on the findings of this report, and then turn to the actions that we are taking as a result.

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. Rather than moments of joy and happiness for these families, their experience of maternity care was one of tragedy and distress, and the effects of these failures were felt across families, communities and generations. The cases in this report are stark and deeply upsetting.

In 12 cases where a mother had died, the report concludes that in three-quarters of those cases the care could have been ‘significantly improved’. It also examined 44 cases of HIE—a brain injury caused by oxygen deprivation. Two-thirds of these cases featured ‘significant and major concerns’ in the care provided to the mother.

The report says that of almost 500 cases of stillbirth, one in four was found to have major concerns in maternity care, which, 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 one case where important clinical information was kept on Post-it notes, which were then 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.

These persistent failings continued until as late as 2019 and multiple opportunities to address them were ignored, including by the trust board, which was 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 CQC rated maternity services inadequate for safety only in 2018, which is unacceptable given the huge deficiencies in care that are outlined in this report.

The report also highlights serious issues with the culture within 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 within weeks of the publication of the report. The first report already concluded that

‘there was a culture within the … Trust to keep caesarean section rates low, because this was perceived as the essence of good maternity care’.

Today’s report adds that

‘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 that across maternity services we focus on safe and personalised care, where the mother’s voice is heard throughout.

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

‘lone voice in the wind’.

Bereaved families told the review that they were treated in a way that lacked sensitivity and empathy and, appallingly, in some cases the trust blamed these 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 with my own 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 this 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 honourable Members and those families who have suffered would want reassurance that the individuals who are responsible for these serious and repeated failures will be held to account. I am sure the House will understand that it is not appropriate for me to name individuals at this stage. However, I reassure honourable 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 also 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 police investigation, I am sure that honourable Members will recognise that I am unable to comment further at this point.

Today’s report acknowledges that since the initial report was published in 2020, we have taken important steps to improve maternity care. This includes £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 be accepting 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 that the recommendations must be acted on promptly.

However, as the report identifies, there are wider lessons that must also be learned, and it contains a series of actions that should be considered by all trusts that provide maternity services. I have asked NHS England to write to all these trusts, instructing them to assess themselves against these actions, and NHS England will be setting out a renewed delivery plan that reflects these recommendations.

I am also taking forward the specific recommendations that Donna Ockenden has asked me to put in place. The first is 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. This will bolster the maternity workforce even further and it will also 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 currently 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 they have taken throughout this distressing inquiry. This 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 this 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 this report is testament to the courage and fortitude that they have shown in the most harrowing of circumstances.

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

My Lords, I thank the Minister for bringing this Statement to your Lordships’ House and for the reassurances he has given and the actions that have been, and will be, taken. I listened to this Statement in great sadness and shock, as I know that so many others have as they heard the news unfold. I will start by expressing heartfelt gratitude to the families who came forward. We would not be here today had it not been for their persistence and the resilience they have shown across over 20 years in their fight for justice. I also thank Donna Ockenden and her team for this landmark report. I utterly regret the appalling circumstances in which it has come before us.

Today marks an important milestone for hundreds of bereaved families who are seeking justice. As the Minister said, it is not the end, because West Mercia Police are investigating some 600 cases. This report lays bare the disturbing truth of what families have had to face and why their fight for justice has been so fierce. The inquiry examined cases involving nearly 1,500 families in instances crossing over decades. It concluded that hundreds of babies were stillborn, died shortly after birth or were left severely brain damaged, and that mothers died giving birth while others were made to have natural births despite the fact that they should have been offered a caesarean. This must have been cruel. The report says that over 200 babies and nine mothers might have survived if they had received the right care.

In addition to what we have read about the actual circumstances, the report also has huge implications for the future of maternity care. The report, of course, makes for harrowing reading—cries for help going unheard; parents having to try to resuscitate their own children because there was no one there to help; and women and babies dying needlessly because the mothers were not listened to. That women were silenced and ignored at their most vulnerable, when they were relying on the NHS to keep them and their babies safe, is shameful. In addition to the NHS, the CQC also failed in its duties as it missed opportunities to stop the poor maternity care.

No woman should ever have to face going into hospital to give birth not knowing whether she and her baby will come out alive. However, these were not just one-offs or isolated incidents of negligence. There was an institutional failing in a system riddled with a toxic culture of bullying, ignoring mothers and deliberating keeping caesarean rates low, even though that was not the right thing for the mother. The entire culture failed to take up the many opportunities to realise that there was a serious problem and to act. We are where we are today because of the persistence and resilience of the families who have suffered, and continue to suffer, and because of their refusal to give up the fight to expose these failings.

The only comfort we can offer them is that their voices have been heard, and that we commit today, in your Lordships’ House, to ensure that these failings are never repeated. For too long, patient safety issues and the voices of women have been an afterthought, leading to the kind of crisis we saw in this NHS trust—and this must change. There can be no compromise on patient safety, which has to be a priority for both health professionals and Ministers.

With this in mind, I will put some points to the Minister. I certainly welcome the acceptance of all 84 recommendations, but how will the Minister monitor the progress that is being demanded through these recommendations, and when and how will this be reported to Parliament?

The report makes it clear that safe services cannot be run unless there is a culture of transparency and accountability. Can the Minister therefore explain how he intends to ensure an open culture within the NHS, with a willingness to learn, particularly within maternity services, and for future failures to be identified and corrected quickly?

Underpinning issues in maternity care, as is the case across so much of our NHS, is the workforce, which is why we have been pushing so hard on this matter in the Health and Care Bill. The NHS is now losing midwives faster than it can recruit them. A recent CQC survey shows that almost a quarter of women were unable to get help when they needed it during labour. Hundreds of pregnant women were turned away from maternity wards last year because there were not the staff available to care for them. What is being done to ensure that the NHS can recruit the midwives that it needs? What is being done to keep the midwives we have in post?

It is only with the necessary workforce that the NHS will be able to ensure that women receive the care that meets their needs and prioritises their safety. That security and respect is all that the families who suffered so much at Shrewsbury want, and it is all that the women who put their and their babies’ lives in the hands of the NHS want. This has to be reasonable, and it has to be done.

My Lords, I too thank the Minister for repeating the Statement. We must acknowledge that the vast majority of midwives, nurses and clinicians providing maternity services do their very best to provide good care for their patients. It must have been with great sadness that they read—as we read with great sadness—today’s Ockenden report and the previous interim report, which have shone a light on a shocking range of shortcomings in maternity services, leadership and inspections at Shrewsbury and Telford Hospital NHS Trust. I hope that this report will lead, in future, to mothers and babies being as safe as we can possibly make them in our NHS.

The report has been made possible only by the bravery and persistence of all those families who were prepared to go through their trauma all over again when they gave evidence of what happened to them and the awful consequences and pain that followed. From these Benches we offer our thanks and sympathies to all those suffering bereavement and ongoing health issues. The report is also a tribute to the fine work of Donna Ockenden and her team, who used both their professional knowledge and their human qualities to conduct the review with dedication, empathy and attention to detail.

I also commend those members of staff who were prepared to give very candid evidence to the investigators. Such people are sometimes referred to as whistleblowers; I call them courageous, public-spirited professionals. However, their actions were not without risk to themselves and their future, as with many whistleblowers in the health and care services. I therefore ask the Minister: will the special health authority, which is being set up to continue the maternity investigation programme currently run by the Healthcare Safety Investigation Branch, have the same safe-space confidentiality for those giving evidence in the future as the HSSIB, which is currently being legislated for in the Health and Care Bill? The Minister will know how strongly both Houses of Parliament feel about the importance of giving staff absolute confidence that the material they disclose remains confidential in the interests only of learning and improving patient safety rather than laying blame.

The report stated that:

“There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the Trust and a culture of not listening to the families involved.”

I therefore first acknowledge last week’s funding announcement of £127 million by NHS England for maternity services, although this is still significantly short of the £200 million to £350 million recommended by the Health and Social Care Select Committee in June 2021. However, it is surprising to me, in the light of Donna Ockenden’s clear finding that staff shortages risk lives, that the Government, in the other place, continue to resist the amendment of the noble Baroness, Lady Cumberlege, voted for by your Lordships, on assessing, reporting and planning for safe levels of staffing in the NHS and social care. Proper planning cannot take place without an accurate and independent assessment of current supply and future need. In light of the Ockenden report, will the Government change their position on this?

There are currently 2,000 midwife vacancies in the NHS, according to NHS England figures published last month, and the number of midwives in post has fallen since last year. This is going in the wrong direction.

In the debate on the interim report in your Lordships’ House on 14 December 2020, the noble Lord, Lord Bethell, denied that the issues in Shrewsbury and Telford maternity services were linked to understaffing. Does the noble Lord, Lord Kamall, now accept that staffing is an issue? Can he say what will be done about it? As Ms Ockenden rightly says, we need to create a situation where midwives, nurses and clinicians want to remain in the NHS. We will not do that if they are constantly having to battle against staff shortages.

The report also highlights the need for women to be listened to when engaging with maternity services, rather than experiencing a culture of services based around targets for a particular kind of birth. I need hardly say that giving birth is a very personal matter and women’s preferences must be listened to and provided where clinically appropriate. Ockenden emphasised that listening to women and empowering them in their care will lead to improved outcomes. I therefore remind the Minister of the parallel between this situation and telemedicine abortion treatment, where the Government are failing to listen to women’s clinically safe preferences. I was pleased to hear recently that Members of the House of Commons have been listening to women, rather than to the Government.

The report pointed out that what happened in Shrewsbury and Telford was not an isolated incident. In July 2021, 41% of maternity services in England were rated as inadequate or requiring improvement. That is why the report made 15 recommendations aimed at all maternity services across the country, and I understand that the Government have accepted them all. Can the Minister therefore say how implementation of these country-wide recommendations will be monitored and reported on? Will that duty be given to the CQC or will there be a special system?

I finally turn to training. In the debate on the interim report in December 2020, my noble friend Lord Scriven pointed out that:

“In 2017, the £8.1 million national maternity training fund was withdrawn. Does the Minister now, in hindsight, regret this, and will he seek to re-establish this fund urgently?”—[Official Report, 14/12/20; col. 1522.]

I echo his question today. Will the money for training be ring-fenced and will midwives going for training always be covered by similarly experienced staff?

Despite earlier events, similar although smaller in scale to what happened at Shrewsbury and Telford, there has not been systematic integrated change. Can the Minister therefore assure us that this will happen now, especially under the new regime of integrated care systems? Who will be responsible at the level of NHS England, ICSs and individual trusts, as well as politically, for ensuring that, this time, the changes highlighted by Donna Ockenden are implemented in a timely way, so that no more families will be avoidably deprived of their precious child, mother or wife?

I begin by thanking both noble Baronesses for their questions and resisting the temptation to bring too much politics into it. This is an issue that we all feel very strongly about. I will try to answer as many questions as I can; I apologise in advance if I do not answer all the questions today. I have quite a big briefing pack, which I have been through a number of times. I commit to writing to noble Lords and the noble Baronesses to fill the gaps.

As the noble Baronesses said, we accept all the actions outlined in the report. The Secretary of State has asked NHS England and NHS Improvement to write to all the trusts across England about the final Ockenden report, and will ask all maternity services across England to assess their services against the 15 immediate and essential actions outlined in the report —and take action where they fall short. As the noble Baronesses acknowledged, NHS England and NHS Improvement have announced that they will invest £127 million in maternity care; that money will go towards the NHS maternity workforce and improving neonatal care.

We have also seen work under way to tackle some of the key issues in the report, such as the £5 million for the Avoiding Brain Injury in Childbirth collaboration project, the establishment of a special health authority to continue the work, which I shall go into later, and the development of 17 new maternal medicine networks. We will update the House as appropriate on the monitoring.

We have to look at the culture; I completely understand the points made. Strong leadership will now be established across the system, with the appointment of named regional and local maternity safety champions led by two national maternity safety champions, Matthew Jolly and Jacqueline Dunkley-Bent. In every trust, front-line maternity safety champions—one obstetrician, one midwife and one neonatologist—will work closely with a board maternity safety champion to promote unfettered floor-to-board communication. We have also tried to make progress in shifting away from a defensive blame culture in healthcare towards a culture in which we recognise and accept when things go wrong and look to learn.

I thank noble Lords for their engagement, particularly over the HSSIB, during the passage of the Bill. I think we all agreed that it was important that we kept as many people as possible out of the “safe space” to encourage people to come forward. However, as we have seen in these cases, people were bullied and disincentivised from coming forward; some even withdrew their names.

Last year, there was a £500,000 fund to provide maternity leadership training for NHS maternity and neonatal leaders. We looked at addressing the issues raised in the first Ockenden report—to use that phrase again, “between ward and board”—to make sure that there was proper accountability and training.

On workforce, as I said, NHS England and NHS Improvement have the investment. In addition, there is £95 million in new funding to support the recruitment of 1,200 more midwives and 100 more obstetricians, and to support multidisciplinary team training. The department has also commissioned the Royal College of Obstetricians and Gynaecologists to develop a new workforce planning tool to improve how maternity units calculate their medical staffing requirements. The tool will calculate the number of obstetricians at all grades required locally and nationally to provide a safe, personalised maternity service within the context of the wider workforce. Health Education England has also been working with stakeholders towards a targeted increase of 3,650 midwifery student training places by the end of 2022-23.

One concern that was raised when I spoke to officials and asked for briefings before this evening was whether reports such as this one would disincentivise people from coming forward to work in midwifery. We have to be very careful that we are as open as possible and that we make sure that the system learns where there are problems. People are human, and they will be concerned about coming forward. So we have to get the right balance and have safety, training and awareness all the way through, making sure that it is patient-centred.

I shall try to answer as many questions as I can; I know that other noble Lords want to come in. In terms of deterring midwives from leaving—I know that there is a real concern here—the NHS people plan focused on improvement and retention. There is a well-being guardian role focused on: healthy work environments and safe spaces; empowering line managers to hold meaningful conversations; emotional and psychological support; a dedicated health and care staff support service; a bereavement helpline; free access to a range of mental health apps; a range of counselling and talking therapies; and online resources. Money has also been invested in 14 mental health hubs across the country, and £6 million has been set aside for a national support service for critical care staff.

We have to tackle bullying and harassment in the service. The people plan deals with a number of issues on that; there is also a visibility and respect framework and a toolkit. A number of projects and pilots are under way across the NHS to support organisations to see what works and where we can learn from that.

There were some questions about the special health authority, which we see as a key part of work to improve the investigation and learning culture. The investigators will carry out timely and independent individualised investigations into maternal and neonatal deaths and incidents across England. The SHA’s investigation will be family-centred and mother-centred, but it will also provide families with answers to questions about why an incident occurred or why their baby died, rather than just sweeping this away. The learning from these investigations will be shared at a local level and across the wider system. As an independent body, the special health authority will continue the work of the HSIB from 2023, and maternity investigations will continue during this time, without interruption, until the SHA is fully operational—this is specifically for maternity.

As for what the Government are doing to make sure that women’s voices are heard, we have the women’s health strategy—I know that noble Lords have heard that before—and we are looking at multidisciplinary training in the maternity workforce. There is a debate within the training community about whether you train someone to be a midwife first or whether they should start as a nurse and have nursing skills first. I will stop there to allow other noble Lords to ask questions.

My Lords, this is a deeply shocking report, and I applaud the Minister for the way in which he has responded. Above all, I of course applaud Donna Ockenden for the formidable clarity of the way in which she has taken the evidence and, without emotion but with great empathy, set out the 84 recommendations and the 15 “Immediate and Essential Actions”. Of course, some of this is about resources, and the Minister has made some statements about this and the fact that, however much we have, we will always want more, but I welcome the resources invested in this.

More important to me is the issue that the Minister touched on about multidisciplinary training. Midwifery has often been an area where there is almost tribal warfare between the midwives and the obstetricians and gynaecologists. Passing a patient on to a gynaecologist has almost been seen as an act of failure. Time and again, we see delays and this ludicrous target of a low caesarean rate. There has been a phenomenal fall in maternal and perinatal mortality over 100 years, but, at the same time, women now have babies when they are older, and babies are larger. There surely must be the interdisciplinary training that the Minister has referred to and that is so important—and the working group with the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives.

Lastly, I come to this deplorable culture where doctors bury their mistakes. It has always been the case in the medical profession that there has been a reluctance to acknowledge failures and problems, saying, “There’s been a problem. Let’s put it aside. Don’t trouble the families with the truth; it’ll upset them more”. This culture of concealment is totally destructive. There are many other professions where mistakes and errors—goodness knows, much of this happens in the heat of the moment—are used as examples from which others can learn, not with a blame culture but with a culture of learning and progress.

I very much congratulate the Government on their approach. This has been a terrible example of groupthink and lack of action, and all of us must be vigilant over whatever institutions we are working with in whatever part of the health service.

I thank my noble friend for her points. I will take this opportunity to elaborate a bit on multidisciplinary training in the maternity workforce. Some £26.5 million of the £95 million invested in maternity services last year will allow training aimed at how multidisciplinary teams work together. There is a new core curriculum for professionals working in maternity and neonatal services—this is being developed by the maternity transformation programme, in partnership with professional organisations, clinicians and service users, to address variations in safety training and competence assurance across England. A single core curriculum will enable the workforce to bring a consistent set of updated safety skills and continue to learn. It is important that we have collaboration and close working relationships between midwives and obstetricians because that obviously benefits the mothers and babies within their collective care. The noble Baroness has already said that this has to be mother-centred and patient-centred.

I also thank my noble friend for highlighting the fact that the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists have been clear that the professions must work together collaboratively. We expect all maternity services to act on the recommendations.

We also have to make sure that staff feel able to and confident about speaking up, as my noble friend said. The Government have taken this issue seriously. In response to a recommendation from Sir Robert Francis’s Freedom to Speak Up review, we established the independent national guardian, to help drive positive cultural change across the NHS and, in addition, to provide support to a network of local freedom speak-up guardians. We will have to see how that works, what can be done better and how we can improve it. Putting in one measure will not solve all these problems. There is no silver bullet, but one of the reasons to put this in at local level is to see where it works and where it does not, and what we can learn from that.

My Lords, I also thank the Minister for the very sensitive way in which he has dealt with this Statement and, like others, commend those parents who have fought for years to be heard. I also commend Donna Ockenden for an outstanding report that makes really harrowing reading.

To follow up on the question asked by the noble Baroness, Lady Bottomley, about training, it has struck me for many years that the competition between midwives and obstetricians is extremely damaging. It was there when I was a medical student and it has not changed. The bullying culture on the wards has I think been almost endemic and right across the system. I hope that the colleges will look at training jointly from day one, not just after qualification, because that team building needs to happen very early. The way the midwifery tutors and the obstetric tutors deal with their trainees must be integrated from day one and then follow on into continuous professional learning. So my first request is that that message goes back very clearly to the schools of midwifery and to the obstetric training courses.

My second point relates to the CQC, which has done a great deal to raise the quality of care across the NHS and is often to be admired. However, it is worrying that it took so long for it to realise that there was a problem. That would suggest that, internally, its benchmarking of what was normal was at a level that is actually unacceptable. I hope the Minister will be able to go back to the CQC and that the CQC itself will be supported to radically rethink the way that it looks at maternity services. I hope that it will be prepared to have some extremely difficult inspections, consultations and conversations with staff in some units that were previously thought to be doing well, but where it might discover that there is bullying and, particularly, this closed-ranks culture that was so evident in the way people responded to the report. But, overall, I think we are all grateful for the openness of this report and the openness with which the Minister has brought it to our notice.

I begin by thanking the noble Baroness, Lady Finlay, not only for her questions today but for the advice she has given me over a number of months since I started in this post. I have learned so much from the noble Baroness, especially from her courage to speak about her own professional experiences and admit where there are issues that need to be addressed. I am very grateful for that.

I completely take the point about working together from day one because, if you do that, you embed that culture of collaboration from day one, rather than just training people and then saying, “Oh, by the way, don’t forget to work collaboratively”. I think that has to be bred into the system and it is something we have to understand.

The other principle, which all noble Lords discussed in debates on the Bill, is the concept of a safe space. In an ideal world, we would find out who was responsible and they would be held to account, but what is really important is that we learn from that and the system learns from its failures. We have to encourage the ability to have a safe space where people feel confident about speaking up. We saw incidents where people felt bullied into not speaking up or where they withdrew their statements. If we can get this through the SHA and throughout the culture of the new HSSIB, this would be a really important first step. I thank noble Lords who, during the debate, pushed for the removal of certain bodies in order to make sure people felt comfortable coming forward.

On the CQC, there are real questions about the inspections in 2014 and 2016 and why it did not recognise safety concerns at the trust. Subsequently, the CQC did recognise the issues and place the trust in special measures. There was some progress made by the trust following this, and there were two subsequent visits. As a regulator, the CQC holds providers to account and makes clear where improvements must be made, but I think it recognises that there are lessons to be learned. There are lessons to be learned not only in government but across the health and care sector. It is important that we look systemically at how we work together and address some of those concerns.

My Lords, I also thank the Minister for the sensitive way in which he has addressed this very difficult statement.

I was particularly moved by the fact that there are empty bedrooms. I have a daughter who is 31. I took a long time to get pregnant and, at the very end of my pregnancy, I woke up and said that I was ill. I went to hospital and my husband said to me, “I don’t think you’re ill, I just think you’ve never had a baby before”. But as the day went on, he came to see me, and apparently I said to him, “If anything happens to me, you will look after our child, won’t you?” He said it frightened him because I am not given to drama. He went to the midwife in charge of the ward and said, “I’m really worried about my wife”. It was taken seriously. I had a scan, and—the noble Baroness, Lady Finlay, will know that this is very rare—I had a rare form of pre-eclampsia in my liver, called HELLP syndrome. In 10 minutes, I had a caesarean section. I was ill for several months and my daughter was in ITU. She has a bedroom at home—she does not live in it except when she comes back—and it has really made me think, not just about the women who lost families but about how much we train healthcare professionals to listen to the significant other of the person. We have not said a lot about that today. That significant other may be a husband, it may be a man, it may be a same- sex partner, but I urge that training includes listening to the significant other.

I also want to raise that strengthening clinical reporting at board level is essential. I and others did research after the Francis report, where it was very clear that boards were not spending significant time looking at clinical issues but were looking at financial issues. That changed then, but I believe the Ockenden report reminds us that there should be further NHS guidance to boards about their responsibility for examining mortality and morbidity rates in order that that is kept closely under supervision at board level. Believe you me, as an ex-deputy chair of a trust, I know that that was one of the most important things I looked at. I chaired the clinical audit committee and I know that those are the things that can pick up recurring issues early and enable boards to look at what is actually going on in the system. We do not want to have another Ockenden report that may not be about midwifery but about something else.

My final issue is to re-emphasise that we must get workforce planning right for the whole of the NHS, not just midwifery—though I welcome everything the Minister has said in relation to midwives and obstetricians.

I thank the noble Baroness, Lady Watkins, for sharing a very personal story. It must have taken quite a bit of courage to share that with us so publicly.

The noble Baroness talked about the “significant other”. Sometimes we consider ourselves the insignificant other. I remember when I became a father about 20 years ago for the first time. When you watched the TV programmes, they quite often told the father, “Go and have a smoke and come back. We’ll let you know.” Clearly, nowadays, you would not advise anyone to go and have a smoke. I remember how involved I was allowed to be. I was in the room for 22 hours for the first birth. Pre-natal care was fantastic, but once the baby was born, my wife was ushered into a bathroom, and I was sent away somewhere else. I could hear her voice. She called me. When I went in, she was sinking into the bath; she was just too exhausted. She was terrified and did not have the strength, and I pulled her out. It might have been a tragedy—I do not know—but it shows that even little things like that could have made a huge difference.

We are all grateful when a wonderful new life comes into this world. Let us think about the preparation that families go through—they prepare a separate room; families buy baby clothes and toys for everyone, expecting that bundle of joy to come home. When that is cruelly snatched away from them due to incompetence, we have to make sure that it happens as little as possible in the future. We know that incidents will occur. It brings a lump to the throat.

Noble Lords will recognise that there has been a debate on workforce. There is a debate in government on it. We shall just have to see how that resolves itself. I have heard loud and clear from noble Lords that it is not only about the maternity workforce; it is also about the wider NHS workforce, as well as making sure that we learn from incidents like this and build in that culture of prevention but also openness when things go wrong.

My Lords, this has been a rather unusual Statement in many ways, not just because it raises such extraordinarily profound questions but because it calls up such deep experiences for everybody around the House and for everyone who has a child or grandchild who survived this still-dangerous procedure. We are indeed indebted to the Minister, to Donna Ockenden and to the parents. It must have taken huge courage to relive all that, because the trauma never fades when one has had that sort of experience. One lives with it.

It is an unusual Statement because of the quality of the experiences around the House. I cannot add to them, but I want to follow up the concern of my noble friend on the Front Bench about monitoring. It is extremely important that we have a clear idea of the trajectory of the implementation of the recommendations and the speed at which they are implemented, because “promptly” is used in the report and the Statement. It is important that we have an idea also of their impact on the ground in terms of the experience of the staff and the patients in that very hospital. That is the only way in which we will know whether these recommendations and the relationship between them are having an impact.

For example, I do want to lower the tone by talking about money, but the Statement makes reference to £127 million. Over what period are we talking about that as an investment? How will it be distributed? Where will the emphasis be placed? Some of things identified are fundamentally important but elusive. How will that be reflected in changes to the quality and quantity of leadership training available? We all know that this is a failure of leadership in so many ways. For a long time, the NHS has been struggling with ways of coming to terms with developing creative leadership which will not condone blame, evasion and avoidance but embrace the need for change and improvement, and transmit and cascade that. These are specific questions. This is such a serious point of inflection in maternity services that we need to know how this is going to come back to us from the department and the Minister, so that we will be able to understand and keep tabs on what is happening. I would be grateful if the Minister could address that.

The noble Baroness raises some important issues. Looking at the big picture, as I say, we have accepted the actions made in the report, and I have asked for a timeline for the implementation from the NHS. However, I commit to updating the House when I can. I will also go back to the department and ask some more questions and make sure that I will write to noble Lords who took part in the debate in order to fill in the gaps.

A number of different issues were raised with regard to the £127 million for next year. That is for next year and it is in addition to £95 million in 2021 to try to recruit 1,200 midwives and 100 consultant obstetricians. Work is also under way as part of the largest nursing, midwifery and allied professional recruitment drive in decades. Since September 2020, there are other initiatives, such as the new non-repayable training grant of at least £5,000 per academic year for eligible students. There is extra funding of up to £3,000 per academic year to eligible students for child dependents, and £2,000 per academic year for those studying specialist subjects. There is also a new grant of at least £5,000 in addition to maintenance and tuition fees provided by the Student Loans Company.

An extensive NHS England and Improvement support package is also being developed to allow NHS trusts to establish and expand ethical international midwifery recruitment—I know that noble Lords have raised many issues about that. Health Education England has also pledged money to fund additional clinical placements, including for nursing, midwifery and allied health professionals and healthcare science, and the Government have provided almost £450,000 to the Royal College of Obstetricians and Gynaecologists to develop a new workforce planning tool. It is very easy to talk about large sums, but these are specific examples of what we are doing. However, I will write to noble Lords with more details.

House adjourned at 7.47 pm.