Michelle Welsh

I want to start by thanking the Secretary of State for making maternity and neonatal safety a priority and for publicly stating that as her priority from the outset. Personally, it felt like a relief, especially after the uncertainty there has been. I wish to personally thank her for that. Baby Loss Awareness Week is a time to remember the babies we have lost, stand alongside bereaved families and recognise that pregnancy and baby loss can change a life forever. Behind every case discussed in this House is a baby who is loved, a family who imagined a future, and a life that will always be part of theirs. In preparing for this debate I watched last year’s debate again, and what saddened me was how much of what we raised then remains painfully familiar today—families still fighting for answers, women still describing concerns that were dismissed, staff still frightened to speak up. Last year I said that grief must be the engine for change. Today I want to go further. Families have carried the grief. It is time that the system carried the responsibility. There has been an important change over the past year. Baby loss, maternity safety and neonatal care are being discussed openly and treated as Government priorities. The work of Donna Ockenden, Baroness Amos and Lady Justice Thirlwall has brought devastating failings into sharp focus. I thank them, their teams and, above all, the families whose courage made that work possible. For the last six-and-a-half years I have fought for change and listened to over 1,000 families and organisations, my own experience of miscarriages and birth leaving me with both physical and mental scars. I am so proud to serve as the Government’s national maternity and neonatal adviser and contribute to the national taskforce. The taskforce brings together families, clinicians and others with the experience and expertise to shape reform. Bringing those voices together in this way is a significant step forward, and I welcome the determination to work together. I also wish to thank the civil servants working behind the scenes, often to demanding deadlines, to turn that determination into action. The measure of our success will be what changes for women arriving at hospital frightened, the midwife trying to keep them safe and the families who sadly leave without their baby. Our goal must be clear: safe care, informed choice and compassionate births, with support that continues when things go wrong. That must be the standard that every family can expect. That includes families experiencing early pregnancy loss. We must never confuse an early loss with a small loss. A woman may have known she was pregnant for only a short time. She may have already imagined a name, a face, a future. She may be grieving privately before she has told anyone that she is pregnant. Whatever her circumstances, she deserves compassion. We must think about where care takes place. A woman who has just been told that her pregnancy ended should not have to sit beside someone celebrating a reassuring scan. A woman losing her baby should not be placed on a ward where she must listen to other babies crying and families celebrating their arrival. We should not ask people to endure avoidable distress because the service has failed to consider their needs. We need appropriate private spaces, timely assessment and scans, sensitive explanations and clear information about what happens next. Women need to understand their treatment choices. They need pain relief, follow-up and someone to contact when they are frightened or unsure. Partners need support too. A woman should never be left feeling that because miscarriage happens relatively often, her own loss somehow matters less. The care we provide cannot remove that grief, but it can make the difference between being supported through it and being traumatised further. That brings me to something very simple: time to care. In Nottinghamshire, when someone is struggling we often say, “Come on, let’s have a cuppa.” We put the kettle on and make a brew, but what we really mean is, “Stop for a moment. Take a breath and sit down. I’m here and I’m listening.” In maternity care, time matters: time to hear a woman say something feels wrong, time to explain a scan result, time to answer a father’s question and time to sit with parents after devastating news. A hurried conversation can leave someone frightened and confused. A compassionate conversation can help them understand, feel heard and know what support is available. We cannot ask staff to provide that care while giving them neither the time nor the staffing to do it. Time to care must be built into the service. That means a properly funded, ring-fenced perinatal workforce plan and enough midwives, obstetricians, neonatal staff, sonographers and bereavement specialists with the training and support they need. It means continuity whenever possible so that women are supported by professionals who understand their history, their fears and their circumstances. Compassion must be supported by the way in which we organise and resource care. Listening must also lead to the right action. We need timely access to the right scans, skilled interpretation of the results and prompt referral when concerns are identified. Safe, informed choice depends on having that information and the opportunity to discuss it. We must also confront the inequalities in whose concerns are heard. Black, Asian and ethnic minority mothers continue to face an unacceptable disparity in maternal outcomes. Racism, assumptions about pain and failures to listen must be addressed directly. We need services that take women’s symptoms seriously, provide appropriate interpretation and examine outcomes honestly. A national improvement in safety cannot be judged a success while some women remain much less safe than others. Where you live, the colour of your skin and your ability to make yourself heard must never determine whether you receive compassionate, safe care. It would be an omission on my part if I did not speak about responsibility and accountability, because I know how deeply this hurts in Nottinghamshire. Women were left traumatised. Families described fathers sleeping on windowsills only hours after their precious baby had died because there was not even a chair available. Some of those who held senior responsibility during those years did not engage with Donna Ockenden’s review. For families who have revisited the worst moments of their lives to help establish the truth, that refusal hurts. It runs deep. It stings. Families have answered the difficult questions. They have shared intimate details. They have found the strength to speak when speaking has cost them so much. They deserve answers from those who held responsibility. For far too long, we have had a system in which excellent midwives are frightened to speak up and families must fight for answers—and some explanations they have been given are clearly untrue. Women have been made to feel that what happened was their fault. We have to address that. A culture that supports honest learning must protect staff who raise concerns and distinguish between human error and reckless or dishonest conduct. It must also ensure that failures of leadership have consequences. Protecting staff who speak the truth and holding people accountable for concealing it are both essential to safer care. That is why the maternity and neonatal commissioner must have teeth. The commissioner must have the independence, authority and resources to listen to families and staff, identify patterns, obtain information and challenge failures. There must be clear routes to require a response and escalate concerns when organisations fail to act. Families should not have to wait for another major inquiry before someone in authority listens. National oversight must be matched by accountability in every trust. Every trust board should be able to say who is responsible for maternity safety, what concerns have been raised, what action is being taken and how progress will be demonstrated. Improvement plans should have named owners, deadlines and evidence that care has changed and improved. We also need consistent national data that helps us identify warning signs early, and accountability must reach the ward, the boardroom and the organisations overseeing them. We must therefore review our regulatory bodies and how they are fulfilling their purpose. The GMC, the CQC and the Nursing and Midwifery Council have different responsibilities, but all have a role in protecting patients. We need to examine how they respond to concerns, share information and act when warning signs emerge. We have those three regulators, yet families still need large-scale investigations to establish what happened and secure change. The question is simple: how could serious concerns at Nottingham University hospital trust have persisted for over 20 years while bereaved families had to stand up, organise and fight before meaningful change began? That is a broken system. A system that leaves grieving parents to expose its failures is unfit for purpose, and when it forces those parents to fight for the truth while carrying the loss of their baby, it is cruel. We should call out that cruelty. We should reject it, and we should change it. Bereaved parents should never have to become the safety net for a system that failed their children. I know that there are exceptional midwives and obstetricians working every day across this country. They listen, they care, they save lives and many have themselves fought to raise concerns. They too deserve a system that supports them, protects them when they speak up and acts on what they say. It is for those staff, for the future of our services and, above all, for babies, mothers and families that we must make change happen. I welcome the Health Bill’s proposal to extend the time limit for bringing relevant prosecutions from three years to five, but we must go further. Families facing bereavement can spend months simply trying to survive, and understanding a complex regulatory system should not fall entirely on them. They need clear information about where to raise concerns, what each organisation can do and how to access support.