Contribution
It is a pleasure to serve under your chairship, Ms Jardine. I echo the thanks given by my hon. and learned Friend the Member for Folkestone and Hythe (Tony Vaughan) to all the petitioners who signed the petition, including 262 of my Shipley constituents.
My interest in maternity safety goes back to the time, over a decade ago, when I was director of policy at the King’s Fund. We set up an inquiry into the safety of maternity services, which was chaired by Baroness Professor Onora O’Neill. Despite the fact that that work was done more than a decade ago, the failures that we hear about today are sadly all too familiar. What struck us at that time was that there had been many reports in the preceding decade, including confidential inquiries into maternal and infant deaths, and that the recommendations had not been implemented. It makes me angry that there has been another decade of more inquiries and reviews, with the recommendations going unheeded.
That is why I am pleased to be an officer of the all-party parliamentary group on patient safety, and why I have worked with my hon. Friend the Member for Morecambe and Lunesdale (Lizzi Collinge) and the right hon. Member for Godalming and Ash (Sir Jeremy Hunt) to make maternity safety one of our priorities on the APPG. It has been fantastic to join colleagues, including my hon. Friends the Members for Sherwood Forest (Michelle Welsh) and for Rossendale and Darwen (Andy MacNae), across all-party parliamentary groups to share our insights and to contribute to the Amos investigation. There are still some of the same issues we heard about in the King’s Fund inquiry a decade ago: poor teamwork, weak accountability, defensive cultures and a failure to translate learning into sustained action.
Like many Members, I hear a range of stories as a constituency MP. Those are mainly centred on Bradford Royal infirmary, and I want to share the story of a constituent whose son was born with complications from the umbilical cord being wrapped around his neck. A late crash call was made after he had been delivered, but sadly he suffered catastrophic brain injury and was in a minimally conscious vegetative state. The women and her son were sent home with no diagnosis, and the child has grown up with epilepsy and other problems due to his brain injury. Sadly, it seems that midwives falsified the Apgar scores on the record and the time of the crash call. We have heard about defensive practice. We need a culture that changes it.
My constituent wrote to me:
“I have encountered significant barriers in navigating the NHS complaints system, particularly for marginalized communities. Language barriers further complicate the process, often leading to the dismissal of legitimate concerns.”
I am pleased to say that Bradford Royal infirmary has recently received good and outstanding ratings from the Care Quality Commission, for maternity and neonatal care respectively. I know that staff are not complacent about the care they give.
Others have mentioned the clinical negligence complaints system. I am a member of the Public Accounts Committee, and we have looked at how issues with that system have not only a human but a financial cost. One of our conclusions was that patients often pursue legal action because the complaints system itself is so confusing and unresponsive, which echoes the thoughts of my constituent. It is therefore vital that there are timely apologies from clinical staff and that we put in place effective, compassionate local resolutions. That will reduce claims, but is also ethically the right thing to do.
I would be grateful if the Minister could update us on the progress of the David Lock KC review, which we heard a lot about at the Public Accounts Committee. Alongside a better complaints system, we also talked about reform of litigation and potentially a no-fault compensation scheme, which would certainly go some way to creating a better environment. At the moment, families often experience long legal battles following harm, which leads to clinicians and organisations becoming defensive.
I want to finish with a brief example of what happens when people are failed but want to share any learnings with the NHS. My friend Martha’s second child died. It was a homebirth with complications. She started labour at 2.30 am. At 5.30 am she called the delivery suite, and staff told her to call back in a few hours. When she did, they sent out a midwife team who did not reach her until 9.40 am. A few moments later, her waters broke and she gave birth to her second daughter, but there was meconium in her discharge. As Members who are clinical will know, that is a sign of baby distress. The midwives called an ambulance immediately. It was another 19 minutes after the 999 call until the ambulance arrived and oxygen was given. Those minutes after birth were crucial, and that length of time without oxygen would have caused global brain damage and severe disability had their daughter survived. Sadly, she died in the care of Great Ormond Street hospital just a couple of days later.
The point of telling that story is that there are many missed opportunities to provide safer care. If the midwives had carried birthing equipment when they were attending, they could have provided immediate care. If the ambulance had prioritised the call from the midwife, it could have prevented the deterioration.