Contribution
I thank the Secretary of State for her statement and for giving me advance sight of it, and we all thank Lady Justice Thirlwall and her team for their incredibly important work. As the Secretary of State said, the report is both thorough and devastating.
These were crimes that shook our whole nation, and no one who has not lost a child in this way could possibly imagine the depth of the parents’ suffering. The task now for the NHS, for the state and for us as parliamentarians is to ensure that from their unthinkably terrible loss will at least come reliable guards against such a tragedy happening again, for sadly this is not the first or only time that serial, tragic, avoidable deaths have occurred within our health service.
There are themes that recur: the dismissal or undermining of whistleblowers; concerns about institutional or personal reputation, or about organisational disruption, hampering the primacy of focus on immediate patient safety; and because the idea of a healthcare worker deliberately harming patients is, naturally, so unthinkable to decent people, alternative explanations are sought instead.
Today we are not at the stage where the Secretary of State is able to say that the Government accept all the recommendations in full, and we understand that it is a very substantial piece of work. She said that they will consider the entire report and set out a full response. When does she anticipate that will happen? In the time available, I will just ask a few questions on a subset of the aspects here. We welcome the points on the suspicion of deliberate harms protocol. The Secretary of State is absolutely right that the message has to get out that, in such cases, suspicion is enough. We must change the way that people think about that.
The report notes that the existing “freedom to speak up” system has operated unevenly through the NHS, and that there remains a need for a national oversight body, although the National Guardian’s Office is no more. The report says that many NHS staff still do not feel that it is possible to raise patient safety concerns without risking career detriment. What else can be done to establish independent escalation pathways outside the management hierarchy? I worry that some of what is there is being removed. If an individual exhausts a trust’s mechanisms for raising concerns, they could currently go to the council of governors at the trust or to NHS England, but both will be abolished by the Health Bill. So if a consultant reports a concern to the board and does not get a hearing, where do they go? Is the Secretary of State the next stage in that line?
I must also ask about another of the Government’s current proposed changes: the abolition of the Health Services Safety Investigations Body. Neither HSSIB nor its predecessor body existed at the time of the murders and, in any event, HSSIB was not set up to investigate individuals, criminal activity or deliberate harm. However, it did create a legally protected safe space for staff to sound alarm bells confidentially outside the normal line manager hierarchy, and that could help to break silences and contribute to the cultural changes that are required. The report states that HSSIB is at present “fulfilling a needed function”, so will the Secretary of State reconsider the proposal to end it?
To many people, an obvious question arising from these terrible cases will surely be that someone up the chain must have noticed the sheer numbers and the severe statistical anomaly in fatalities. The report notes that there was an alert signal in the data in 2015, but the analysis was only being reported on with a long lag. Clearly what is required is real-time reporting and automated analysis to identify abnormalities in deteriorations or unexplained deaths that triggers immediate and independent external review. The Secretary of State mentioned that the near real-time process is now in place. Can she say how close that comes to being fully real-time and automated—though not only automated but, of course, complementing human understanding—to trigger independent external review? The inquiry’s findings on this also link to its recommendation that NHS systems become interoperable by the end of 2028. Does she think that timetable is achievable?
Recommendation 1, as the Secretary of State mentioned, is on the use of cameras in cots, with remote monitoring for parents, and the Department is to set out a road map by March. Remote monitoring has of course become widespread in people’s own homes, and there is cot-side video in use at quite a number of trusts. But this would be rather more than what is typically in place in those hospitals today. Can she outline her initial assessment of how this can be achieved and by when?
One of the most sobering findings is that in Lady Justice Thirlwall’s review of recommendations from previous inquiries into NHS bodies over 30 years, although some significant changes have been made, many recommendations have not been implemented. She supports the formation of a Joint Committee of Parliament to ensure that recommendations are pursued, and she recommends that the National Audit Office audits implementation of statutory inquiries into the NHS. I think I heard the Secretary of State say they were going to create an internal hub—really? I ask her to consider whether that is enough. Would it not be better, in the spirit of the duty of candour, if these things were done through the institutions—through the National Audit Office and with this Parliament?
Our thoughts and prayers remain with all those families in the unimaginable pain of their loss. Although nothing now can undo that pain, it is vital that all possible lessons are learned and, more importantly, acted upon with determination and urgency.