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Ockenden Review

Volume 685: debated on Thursday 10 December 2020

With permission, Madam Deputy Speaker, I would like to make a statement on the initial report from the Ockenden review, which was published this morning.

Before I update the House on the findings, I wish to remind the House of the tragic circumstances in which the review was established. It was requested by the Government following concerns raised in December 2016 by two bereaved families whose babies had sadly died shortly following their birth at the Shrewsbury and Telford Hospital NHS Trust. I am grateful to my right hon. Friend the Member for South West Surrey (Jeremy Hunt), who, as Secretary of State for Health and Social Care, asked NHS Improvement to commission the independent inquiry.

The inquiry is chaired by senior registered midwife Donna Ockenden, a clinical expert in maternity who was tasked with assessing the quality of previous investigations and how the trust had implemented recommendations relating to newborn, infant and maternal harm. As the report acknowledges, this year the country has rightly united in pride and admiration for our NHS, but we must accept that in the past not everyone has experienced the kindness and compassion from the NHS that they deserved.

The review team has met face to face with families who have suffered as a result of the loss of brothers and sisters, or who have, from a young age, been carers to profoundly disabled siblings. The team has also met parents in cases where there have been breakdowns in relationships as a result of the strain of caring for a severely disabled child or the grief after the death of a baby or resultant complications following childbirth.

The original terms of reference for the review covered the handling of 23 cases; however, since its launch more families have come forward and extra cases have been identified by the trust. As a result, the review now covers 1,862 cases, and this has led to an extension of its scope and delivery. An interim report has therefore been published today, and it contains a number of important themes that the review team believe must be shared across all maternity services as a matter of urgency. Indeed, I personally, and the Government, pushed to have this interim report at this point in time so that we could learn from the findings of the inquiry so far.

This is the first of two reports, based on a review of 250 cases between 2000 and 2018; the second, final report will follow next year. Today’s report makes it clear that there were serious failings in maternity services at the Shrewsbury and Telford Hospital NHS Trust. I would like to express my profound sympathies for what the families have gone through. There can be no greater pain for a parent than to lose a child. I am acutely aware that nothing I can say today will lessen the horrendous suffering that these families have been through and continue to suffer. Nevertheless, I would like to give my thanks to all the families who agreed to come forward and assist the inquiry.

The review team held conversations with more than 800 families who have raised serious concerns about the care they received. I know that it has not been easy for them to revisit painful and distressing experiences, but through sharing their stories we can ensure that no family has to suffer the same pain in the future. From the outset the inquiry wanted families to be central to the team’s work and for their voices to be heard, and I am pleased that the families were able to see the report first, this morning, shortly before it was presented to Parliament. I assure them, and Members of this House, that we are taking today’s report very seriously and that we expect the trust to act on the recommendations immediately.

I thank Donna Ockenden and her team for their diligent work. Their valuable work provides essential and immediate actions to improve patient safety and ensure that maternity services at the trust are safe. Four of those actions are for the trust and seven are for the wider maternity system. The report sets out clear recommendations for what the trust can do to improve safety relating to overall maternity care, maternal deaths, obstetric anaesthesia and neonatal services.

The report also sets out actions that can make a difference to the safe provision of maternity services everywhere. They include recommendations on enhancing patient safety and how we can best listen to women and families, developing more effective staff training and ways of working, managing complex pregnancies and risk assessments throughout pregnancies, monitoring foetal wellbeing, and ensuring that patients have enough information to give informed consent. I welcome those recommendations and the others in the report. We will be working closely with NHS England, NHS Improvement and Shrewsbury and Telford Hospital NHS Trust, which have accepted each of the recommendations and will take them forward. We learn from these tragic cases so that we can give patients the safe and high-quality care that they deserve.

Patient safety is a big priority for me and the Government. We want the NHS to be the safest place in the world to give birth, and this report makes an important contribution towards that goal. Our ambition is to halve the 2010 rates of stillbirths, neonatal and maternal deaths, and brain injuries in babies occurring during or soon after birth by 2025. We have achieved early our ambition of a 20% decrease in stillbirths by 2020, but of course there is always more to do and we owe it to the families to get it right.

The Ockenden review is an important document that vividly shows the importance of patient safety. I assure the House that we will learn the lessons that must be learned so that the tragic stories found within these pages will never be repeated again. I commend this statement to the House.

I thank the Minister for advance sight of her statement and the personal commitment she has shown on this issue. I too thank Donna Ockenden and her team for their work to date.

Sadly, the report is not the first of its nature, and it is unlikely to be the last. We need to get ourselves into a place, sooner rather than later, where these systemic, almost cultural, failings become a thing of the past. The families have suffered unimaginable pain, and it must not be exacerbated by closed and defensive responses to the tragedies they have experienced.

Today’s statement comes only a fortnight after another damning report on maternity safety—Bill Kirkup’s report “The Life and Death of Elizabeth Dixon”. This is the latest in a long line of reports that show that, across large parts of the NHS, there is still a long way to go before we have the openness and transparency that patients deserve. That is not to do down the hundreds of thousands of staff who do a fantastic job day in, day out, but the report points to the wider problem—it is not a new problem—that when things go wrong, there is too little candour, too much defensiveness and a lack of leadership at the top of trusts; the leadership do not take personal responsibility and put right what has gone wrong.

Once again, we have got to this point only because of the persistence and resilience of the grieving families who have suffered such personal tragedy and refused to accept that what they were told was the end of the matter. I want to put on the record my appreciation of the courage and strength that they have shown throughout, but we really should not expect light to be shone on these issues only because individual families do not accept what they are told.

Senior leadership within trusts has to be much more candid and challenging with itself when faced with these concerns.  These families just want answers and an assurance that nobody else will have to go through what they did, but, too often, they do not get them. The fact that we are now looking at more than 800 cases over a 40-year period, when the original investigation was tasked to look at just 23, must surely tell us that, for a very long time, those grieving families were not being listened to and the necessary lessons were not being learned. That in itself is as much a failure as the individual incidents. With so many more families coming forward and having to relive some of the most difficult experiences in their lives, it is vital that support is offered to them to deal with the consequences of that, so can the Minister assure us that appropriate support is available to all those who need it?

So that we will all be clear now, the Ockenden review will be far larger and take far longer than was originally intended. Can the Minister assure the House that the review has the resources necessary to complete the final report as soon as possible? I understand that the trust has not waited until today to take action, but, inevitably, further recommendations will emerge from the final report. There are also actions for the whole NHS, and a number of specific actions that can be taken across the board now, which the Minister indicated are in fact urgent. I would be grateful if she indicated whether she intends to set a deadline for implementation of the system-wide recommendations and whether she will provide regular updates to the House on their progress.

Strong leadership, challenging poor workplace culture and ring-fencing maternity funding are all key to improving safety. On tackling the poor workplace culture that exists in some trusts, it is clear that there is still a long way to go. It is concerning to see a report this morning that the review into bullying at West Suffolk Hospital, which was originally due to be published last April, is now not due until next spring. It is also clear that there is a pressing need to reinstate the NHS maternity safety training fund. That money was vital for safety and makes a big difference to care, so can the Minister commit to reinstating that training fund?

Can the Minister also advise what action is being taken to ensure that we have enough staff in all maternity units, and will the Government commit to legislating for safe staffing levels? More widely, can she set out what is being done to tackle the estimated 3,000 midwife vacancies that we currently have? We cannot ignore the fact that some of the problems created by this culture will be exacerbated and will continue if we do not solve the staffing and resourcing crisis in the NHS, and these issues will continue to compromise patient safety.

Finally, it is understandable if families who are currently receiving care at the trust are anxious. Can the Minister provide them with some reassurance today that they will be safe and well looked after?

I thank the hon. Member for Ellesmere Port and Neston (Justin Madders) for his, as always, constructive and reasonable tone in his response. Yes, I can assure him that the resources are in place, and have been guaranteed to be in place. As for the deadline, it is 2021. I cannot give an exact month. It was really important to me—I believe that Donna Ockenden has mentioned this in her report a number of times— that the first 250 cases were evaluated so that we could take the learning from those cases and introduce it as quickly as possible. In that way, we could identify what had gone wrong so that we could prevent it from happening again in the future. That is why we have produced the report in two stages. We know the findings of this interim report and the recommendations that have been identified by Donna and her team can be put in place. The second stage of the report will appear before the end of next year—certainly in 2021. I will, as the hon. Gentleman requests, and personally if he requires it, update the House on what is happening with the report.

With regard to the maternity safety training fund, we secured £9.4 million in the spending review. It cannot be underestimated, in this time of covid, what a huge achievement that was. The money will not go into the old format of the maternity safety training fund, because we do not believe that that worked as well as it should have done. Much of that money was used to backfill the staff, who then, unfortunately, did not attend training. We did not get the best results—the biggest bang for the buck.

What we, as a Department, are doing now is directing that £9.4 million to where it is needed most and to where it can be spent in the most effective manner to produce results in maternity safety. That work is ongoing now in the Department, and I hope to be able to update the House and the hon. Gentleman very soon on how that money is being spent and what results we expect to see in return for the expenditure.

I did not anticipate the hon. Gentleman’s question about midwives. I do not have the exact number, because the figure rises every day. None the less, we are recruiting new nurses—I think the figure was 12,000 when I last gave a statement to the House—some of whom will be recruited to become midwives. So, yes, work is under way on the workforce and on nurse recruitment.

Babies’ skulls were fractured and bones were broken in excruciatingly traumatic births that would never have happened if mothers’ wishes had been listened to. This is an utterly shocking report, and I think the whole House is immensely grateful to Donna Ockenden and her team for such a thorough report, and to the Minister for taking it so seriously, as she always does.

Although much has improved in maternity safety in recent years, does the Minister agree that it is time to stamp out the “normal births” ideology, which says that there can be a debate or compromise about the total importance of a baby’s safety? That should always be paramount, and decisions on it should always be taken in consultation with the mother. The report team said they had

“the clear impression that there was a culture within The Shrewsbury and Telford Hospital NHS Trust to keep caesarean section rates low”.

That needs to stop—not just at Shrewsbury and Telford, but everywhere throughout the NHS. The biggest mistake in interpreting this report would be to think that what happened at Shrewsbury and Telford is a one-off, as it may well not be and we must not assume that it is.

Secondly, the report talks about the “injudicious use of oxytocin” to facilitate vaginal births that perhaps should not have been happening. Will the Minister look into that issue? Finally, this report happened because Rhiannon Davies and Richard Stanton, who lost their daughter Kate in 2009, and Kayleigh and Colin Griffiths, who lost their daughter Pippa in 2016, persuaded me that something needed to happen. Is it not shameful that we make it so hard for doctors, nurses and midwives in the NHS to speak out about tragedies that they see and that all the burden for change is left on the shoulders of grieving relatives? Is it not time, once and for all, to end the blame culture that we still have in parts of the NHS?

My right hon. Friend asked a number of questions that deserve answers, so please bear with me. His first point was about the number of caesarean sections and the thought or belief in the hospital that it was a good thing not to have them, which the report identifies.

The report shows us that there were years when C-sections at Shrewsbury and Telford were running at 11% and the national average was 24%, and at 13% when the national average was 26%. That demonstrates a lack of collegiate working between midwives, doctors and consultants. Most of the report’s recommendations show that, fundamentally, that is the problem: a lack of communication and an unwillingness to work with people—the medics, doctors, obstetricians and midwives. My right hon. Friend is absolutely right about intervention. There is the old saying, “Mother knows best”, but every woman should own her birth plan and be in control of what is happening to her during her delivery.

I give all thanks to my right hon. Friend, because this report is fundamental in terms of how it is going to inform maternity services across the UK going forward, not least because the NHS is working on an early warning surveillance system. What happened at Shrewsbury and Telford was that it was an outlying trust. As with East Kent and others, including Morecambe Bay, where we have seen issues, there has been an issue culturally; they are outlying, without the same churn of doctors, nurses, training or expertise. The NHS is now developing a system where we can pick up this data and know quickly where failings are happening.

Oxytocin is a drug used in the induction of labour to control the length, quality and frequency of uterine contractions. There are strict National Institute for Health and Care Excellence guidelines on the use of that drug. My right hon. Friend is correct: every trust should follow the guidelines. By highlighting that in this report, we will ensure that trusts are aware of those guidelines and that they are followed in future.

Our heart goes out to all those who have suffered these tragic events and losses; those of us who are parents or grandparents suffer with these families. May I ask the hon. Lady a question as the Minister for Mental Health? The mental health of mothers during and after pregnancy is vital, not just in the tragic circumstance of baby loss or severe injuries during birth. Will she ensure that training in perinatal mental health becomes a strong focus for improving maternity services across the country?

I hope the hon. Lady will not mind my mentioning it, but I know that she is about to become a grandmother herself soon, so I understand the reason for her questioning. She raises a very important point. I know she is aware, because I believe we have had this conversation, that we are focusing on women in the Department at the moment, and of course the mental health of women is a big part of that. The post-natal depression services that have been rolled out across the UK in the past 18 months are a testament to the fact that we are focusing on mental health. I take her point on board, and she has made it before.

I very much thank the Minister for coming to the House so promptly and making this statement, and for her commitment to patient safety. I also pay particular tribute to my right hon. Friend the Member for South West Surrey (Jeremy Hunt) for initiating this very important review. Without that, we would not be here today.

The findings of the report are deeply harrowing. The scale of the deaths and injuries suffered are horrific, but so too was the response of the trust at the time. The report details this. Women at their most vulnerable could not get their voices heard. They were not listened to by those in positions of power, who normalised poor maternity care and also denied its existence. Instead of humility and empathy, what we saw was the harshness of bureaucratic defensiveness, with women at times “blamed for their loss”—that is in the report.

There is now a criminal investigation into this matter, but I would be grateful if the Minister would please ensure that nothing gets in the way of implementing the recommendations as soon as possible, so that families can see real change in maternity care, at this trust and also right across the country.

I thank my hon. Friend for her pursuance, her persistence and her dedication, both to her constituents and the hospital as a trust. I would also like to mention, as my right hon. Friend the Member for South West Surrey (Jeremy Hunt) did, the parents of Kate Stanton-Davies and Pippa Griffiths, who have been instrumental in getting us along the pathway to where we are today. Yes, my right hon. Friend commissioned the report, I pushed for it to happen now, and my hon. Friend has been pushing also, but it is down to those parents and their commitment. It should not have to be like this. Parents should not have to go through what they have gone through to get to where we are today.

As my hon. Friend is aware, I have visited the trust myself and have been round the midwifery unit and the consultant-led unit, and I think there is an anomaly there. Should we have a midwifery unit and a consultants’ unit? Is that not where the problem is, with two separate disciplines not working together? Should there not be just one delivery unit? Does the culture not start there, and should we not look at how it works?

However, my hon. Friend has my absolute 100% assurance that, for as long as I am in this post, I will be driving forward the recommendations and findings of this report.

I thank the Minister for her understanding and compassion on the findings of the Ockenden report. With other right hon. and hon. Members, I wish to express my deepest sympathy to those families who have been grievously damaged by the failings of the Shrewsbury and Telford Hospital NHS Trust.

But will the Minister underline that sympathy alone is not necessarily what is required? What is required is action, and an undertaking to review procedures not only in this trust, but UK-wide, to ensure that the Ockenden report recommendations are implemented in all maternity wards. Will she give a guarantee that that will be done?

I thank the hon. Gentleman for his question; he is absolutely right, of course. The findings will be put in place, and in many trusts they already are. I was just looking for my data on the Morecambe Bay investigation, which I believe my right hon. Friend the Member for South West Surrey (Jeremy Hunt) also commissioned. If we look at the Morecambe Bay trust investigation, the predecessor to this, it is quite commonplace to say—I hear it all the time—“Well, we had Morecambe Bay and nothing has happened: the recommendations haven’t been implemented there.”

Actually, the Morecambe Bay investigation made 44 recommendations, 18 of which have been completed within the Morecambe Bay trust. There were 26 wider NHS learnings and recommendations, of which 14 were accepted nationally and 11 are being worked on now in the Department, to be rolled out nationally. I use that as evidence that reports such as this have consequences: actions that are implemented and make a difference in maternity units.

I add my sympathy and condolences to all those who have suffered loss or damage to their baby or mother in childbirth under the care of the trust, and I also add my voice to thank Donna Ockenden and her large team for the important work that they have done to review so many cases over the past two decades and more. I hope this will help each and every family who have suffered to reach a better understanding of the tragedy of their own case. However, the principal motivation of my then constituents, the Stanton-Davies parents, in coming forward following the loss of their baby daughter Kate, which prompted this review, was to ensure that other parents could be spared the trauma that they went through.

I am grateful to the Minister for her response to this report. In addition to what she has already said, can she tell the House, and the thousands of expectant mums whose babies are delivered by the committed clinicians at Shrewsbury and Telford Hospital NHS Trust every year, about the improvements in safety and standards that prevail now in the women’s and children’s unit? That might reassure them that some lessons have already been learned, that more will continue to be learned on the back of this review in implementing its recommendations, and that the maternity service in Shropshire and Telford provides a safe place for babies to be born.

I thank my right hon. Friend for his question. As he is aware, I have visited the trust. We have a chief executive in place now who I personally, and the Department and NHS England, have been working closely with, as well as with the team in the hospital. The trust has accepted the findings of the report and will take each of the recommendations forward, so that we learn from these tragic cases of the past and can give patients the safe and high-quality care that they deserve. My right hon. Friend was a Minister himself, I think possibly in my role, in the Department when this report was commissioned, so he has been involved with it right from the beginning.

We want the NHS to be the safest place in the world to give birth—I know I say that often at the Dispatch Box—and this report makes a valuable and important contribution towards that goal. That starts in Shrewsbury and Telford, where as I stand here now the recommendations are being discussed within the trust, and ways found both to deliver and to implement the recommendations that have been made, so that from today onwards Shrewsbury and Telford will be a safe place—as it has been for some time, while it has been on our radar and in special measures—for women to give birth.

We are discussing today the traumatic findings thus far of the Ockenden review about the Shrewsbury and Telford Hospital NHS Trust, and our hearts go out to the grieving parents and families. Until recently, the travesty of Morecambe Bay was considered the worst maternity scandal in the NHS, so why have there since been others, and what steps are the Government taking to implement findings of successive inquiries into maternity services across our country?

As I said, the vast majority of the recommendations on Morecambe Bay have been implemented. Of those that were for wider NHS consideration, 14 have been implemented and 11 have not. However, this is not a case of us overnight going out and saying, “Right, this is how you change”—it takes a vast amount of work in policy, process and delivery. Those 11 recommendations are being worked on and have been worked on since the report on Morecambe Bay happened. The hon. Gentleman is right to highlight the fact that we do not have consistency across the NHS in terms of care or delivery. That is what we are working towards. We are currently developing a core curriculum of training that will be multi-disciplinary and we hope will rolled out next year. It will be undertaken by midwives, doctors, obstetricians and everybody working in the maternity unit so that they are all at a certain point of skill in terms of consistency, they are all aware of the lessons to be learned from the past in terms of safety, and they implement the recommendations that go across the UK in maternity units. Most maternity units in the UK operate well and deliver babies safely. We have fantastic maternity services in the UK. However, we do have difficult trusts. As in all disciplines, they are not all the same. This is about the outliers—the hospitals that we are working to identify early. With the core curriculum, we are making sure that everybody working in maternity units across the UK has the same standard and level of training.

I welcome the considered tone the Minister has taken today in responding to the difficult contents of this report and in promoting a clinically led response to the findings rather than allowing knee-jerk political reactions that often do not lead to the right results. Let me pick up on one thing. What we see throughout a number of reports, be it Mid Staffs, Morecambe Bay or now this one, is that management is often central to setting a culture that allows mistakes and deaths to occur. When a clinician is found to be negligent, they have a responsible body—the Nursing and Midwifery Council or the General Medical Council—that can take action against them, but what are we going to do to ensure that managers receive better training and that we stop the revolving door of bad managers who are responsible for poor care being employed elsewhere in the NHS?

I thank my hon. Friend, who, again, is a predecessor in my Department—a former Health Minister. He is absolutely right to talk about strong leadership. Strong leadership has been established across the system. In the context of maternity services, which is what we are talking about, we have the maternity safety champions who are being led by Dr Matthew Jolly, the national clinical director of maternity and women’s health, and Professor Jacqueline Dunkley-Bent OBE, the chief midwifery officer for England. There are lead clinicians who are leading clinically.

In terms of the management of the Shrewsbury and Telford trust, there have been eight chief executives in 10 years. That is not good. Good practice does not come from a revolving door of chief executives and board members who constantly rotate, because there is no continuation of learning, no loyalty, and no commitment to good outcomes at the hospital. We have to change this revolving door of boards and chief executives. The chief executive who is there now has our confidence, and we are assured that she will put in place the recommendations of the report, but my hon. Friend is right: it is crucial that we work on this revolving door of managers and those who are not clinically led, because that is part of the problem. He is right to identify that, and I want to reassure him that it is something we are aware of.

First, our thoughts today must be with all the families who have been affected by this tragedy. The investigation found that an area of concern was having the right staffing levels and the right skills mix. Will the Government look to legislate for safe staffing levels in the NHS and, in particular, midwifery?

It is probably in the Secretary of State’s domain to make that kind of statement at the Dispatch Box, so I cannot give the hon. Lady that reassurance myself, but we are delighted about the huge number of new nurses and doctors that we have in training. Recruitment of our workforce in the NHS is going well, and I hope that that will be the ultimate goal.

Reading this report is utterly heartbreaking, and my heart goes out to the families who have been involved in this terrible situation. Leadership, workplace culture and patient safety clearly go hand in hand, so what steps is my hon. Friend taking to strengthen clinical leadership, in order to ensure that all maternity wards are the safest they can be?

I pay tribute to my hon. Friend for not only his work at Watford General Hospital—he is probably there more often some of the patients—but his commitment to mental health in his constituency. He has launched a programme of 1,000 mental health first aiders, which is a tremendous boost to his constituents. I am aware of his work, and I thank him for it.

My hon. Friend has hit the nail on the head. Midwifery leadership has been strengthened this year by the appointment of seven regional chief midwives, working with local maternity services to ensure the provision of safer and more personal care for women, babies and their families. I am sure that the hon. Member for Ellesmere Port and Neston (Justin Madders) had the same thoughts that I did on reading the report. There is a lack of collegiate working—“Let’s not let the doctors have this. Let’s keep this for the midwives”—and a lack of team working. The recommendations in the report put forward solutions to end that culture and to introduce one where doctors, nurses and midwifery champions work together, as a team, with the mother, who is in control of and owns her birth plan, because that is what it should be about.

It is devastating to read about the families involved in this. We have been here so many times. I think back to the publication of the Robert Francis report in 2013, which particularly talked about the duty of candour and the way that those issues are addressed. Clearly the system is quite passive; it is dependent on people raising concerns. What is the Minister doing to ensure that it is more interrogative of families and those involved in order to draw out people’s concerns at what is perhaps their most vulnerable time, as is the case for many women when giving birth?

The hon. Lady is right: there is a theme. Whether it is Paterson, the Cumberlege review or Morecambe Bay, central to all this is women, and so much of this report is familiar in that women are not listened to. The way some of those mothers were spoken to when they were delivering their babies or during the most tragic hours and days afterwards is just appalling. It is about women being downgraded almost, as though their complaints, their voices or their concerns, and the awful circumstances in which they find themselves are not worthy of the same consideration as patients in other hospitals in other situations.

The hon. Lady is absolutely right. We already have national guardians—they immediately spring to mind. We have 600 national guardians in hospitals. NHS workers wear lanyards and, when people want to highlight something that they have seen going wrong in terms of patient safety, they may speak to that person, who will assist them and raise their concerns. It is quite something when we need that, when patients need such assistance. It is also for staff to raise patient concerns. She is absolutely right—it is about listening and treating the complaints and issues of women seriously.

My heart goes out to the families. I pay tribute to the Minister for her work on this. Although these tragic things go wrong in our national health service, does my hon. Friend note that many good things also happen across our hospitals? Our maternity ward in the Princess Alexandra Hospital in Harlow has been described as “outstanding” by the Care Quality Commission, and is one of the most successful and important parts of our hospital. Will she pay tribute to and thank staff across the NHS, as well as in Harlow, who do so much? Will she also look at best practice around the country, in places like the Princess Alexandra Hospital for maternity, to see what can be done to learn from that best practice to ensure that such tragedies never happen again?

My right hon. Friend adds such a hopeful note. I thank him. He is absolutely right. We stand here to talk about reports, patient safety issues and where things have gone wrong, and yet so much of the NHS so much of the time goes absolutely right. The Princess Alexandra Hospital in his constituency is a shining light and an example of the best practice in maternity services. Of course, we use examples such as Harlow to inform us of how things go right and how well maternity units work. He is absolutely right, and we will of course look at Harlow, as we do at other examples of good service across the NHS, which is—I thank him for reminding us all of this today—in most hospitals most of the time. Our job is to reassure women. The UK is among the safest countries in the world in which to give birth, and most of the time it goes right.

In that case, I thank the Minister for what is clearly a very genuine response to the concerns expressed today. What has been said about the culture within the NHS, revealed in this review, has echoes of the Bristol heart babies scandal, and it is tragic that parents must still fight to have their voices heard now. One of the things mentioned by families contributing to the Ockenden review is the desperate need for longer-term support following experience of baby loss. I know from my constituents that the NHS has struggled to provide that during the current pandemic. What more can we do to ensure not just that parents are listened to at the time of losing their baby, but that they are supported from then onwards, too?

I thank the hon. Lady for her comments, sincerely, and for her important question. Baby loss is something that we discuss in this House—rightly so—and we are discussing what happened at Shrewsbury and Telford, because many parents there lost their babies. The report makes a recommendation that the care and support that parents are given following a bereavement are strengthened, and that measures are put in place to ensure that the right package is there. Many charities work in this area across the UK—I will just mention Baby Lifeline, Sands and others—and have themselves put in place both practical and emotional measures to help parents at such a time. It is the worst time, in anyone’s life, to lose a child. We say that so many times in here, and it is our responsibility, both in the Department and in society as a whole, to hold those parents and to help them through those awful times. I thank the hon. Lady for her question—this is something we take very seriously in the DHSC.

I thank the Minister for her statement and her full responses to all the issues that were raised by right hon. and hon. Members. We will now have a three-minute suspension for the safe entry and exit of right hon. and hon. Members.

Sitting suspended.

Virtual participation in proceedings concluded (Order, 4 June).