Civil Partnerships, Marriages and Deaths (Registration etc.) Bill

Part of the debate – in the House of Commons at 10:23 am on 2nd February 2018.

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Photo of Lilian Greenwood Lilian Greenwood Chair, Transport Committee 10:23 am, 2nd February 2018

Thank you, Mr Deputy Speaker. I will attempt to keep my contribution concise. I congratulate Tim Loughton on bringing forward his comprehensive Bill. I know that he has wanted to act on these matters for a really long time, so this is a real tribute to persistence and determination. I support the Bill in total, but I am going to confine my comments to the issues addressed in clause 4, which deals with extending the powers of coroners to enable them to investigate stillbirths. This will make a difference to many families who need to know why their baby died. Even more importantly, it will ensure that lessons are learned and improvements are made so that other parents are spared the horror of losing a baby. I acknowledge the important work done by the Secretary of State for Health in acting to tackle avoidable harm and death through his maternity safety strategy. I welcomed his support for this Bill when he made a statement to the House on 28 November last year, in which he said:

“I will work with the Ministry of Justice to look closely into enabling, for the first time, full-term stillbirths to be covered by coronial law”.—[Official Report, 28 November 2017;
Vol. 632, c. 179.]

That was an important and welcome development.

Mainly, though, I am here on a Friday to speak for Harriet Hawkins, because she will never be able to speak for herself. Indeed, she never got to draw breath, and, as the hon. Member for East Worthing and Shoreham has explained, that is significant. I am also here to support my incredible and courageous, but heartbroken, constituents, Jack and Sarah, Harriet’s parents. Their fight for the truth has been so dreadful and so unnecessarily painful that we in this House must act to ensure that others do not have to go through the same thing.

Let me explain what happened to Harriet, and Jack and Sarah, and how it could all have been so different. Harriet was Jack and Sarah’s first baby. There were no problems in pregnancy, and Sarah was considered low risk. She began to experience contractions one day after her due date on 11 April 2016. She was in labour for five days before Harriet was eventually delivered. In that time, Jack and Sarah made 10 phone calls and two visits to the hospital, the Queen’s Medical Centre. Each time, Sarah was assessed, reassured and sent home. When she was finally admitted—to Nottingham City Hospital, because QMC was full—an ultrasound revealed that Harriet had died. We might think that things could get no worse, but sadly, we would be wrong. Sarah was left struggling with an over-long labour, and Harriet was delivered more than nine hours later. In the following days, the only contact Sarah and Jack had with Nottingham University Hospitals NHS Trust was with the bereavement midwife. Each time, they explained that Harriet’s death was due to numerous errors. They expected to be contacted as part of an investigation, but that did not happen.

I should say that both Jack and Sarah work for Nottingham University Hospitals NHS Trust. Jack is a hospital consultant—a clinical director in NHS Improvement—and Sarah is a senior physiotherapist. They had an understanding of what they should expect. They knew that something had gone horribly wrong, and when they were told that a post-mortem revealed that Harriet’s death was caused by an “infection”, and told to “try to move on”, they refused to have their concerns dismissed. Following repeated requests, they met representatives of the NUH trust in July 2016. The trust said that it had carried out an investigation—without Jack and Sarah’s involvement—and concluded that there were no errors and that Harriet’s death was down to an infection. As an expert in infections, Jack was able to challenge this conclusion, and he and Sarah demanded an external review. The hospital conceded, and Jack and Sarah met the external review team in August 2016. Following that meeting, Harriet’s death was upgraded to a serious untoward incident, 159 days after she died. That should have happened within 72 hours.

In December, Jack and Sarah were sent a draft report to check for accuracy. It stated that

“Harriet’s death was directly contributed to by five things”.

That conclusion meant a great deal to Jack and Sarah, but when the final serious untoward incident report was circulated, the conclusions had been watered down, stating that

“Harriet’s death might have been avoided if” certain other things had happened. To Jack and Sarah, this significant change smacked of a cover-up, and a refusal to learn from the handling of Harriet’s birth. The trust would not explain why the investigation team had changed its conclusions.

Dissatisfied with the handling of the investigation, Jack and Sarah contacted the clinical commissioning group, which organised a new external review team to conduct a second serious untoward incident investigation. That report was published in December 2017, and it said that there were multiple missed opportunities for intervention and appropriate monitoring earlier in the labour. Had one of those opportunities been taken, it is likely that the labour would have been substantially shortened, with any foetal compromise recognised on CTG. It is therefore likely that intrauterine foetal death would not have occurred:

“The overall conclusion of this investigation was that the death of baby H was almost certainly preventable.”

I do not know how many babies have died or been harmed since Harriet’s death in April 2016, or whether those deaths or injuries could have been avoided if the lessons from Sarah and Jack’s case had been identified earlier. I also do not know how many babies died before Harriet due to similar failings of care, which would have prevented her death had they been identified. Opportunities were very clearly lost, and without Sarah and Jack’s incredible fight there would have been no learning from Harriet’s death.

Sarah and Jack wrote to me earlier this week:

“We have always said had we not been clinicians we would not be here today, fighting. We would have believed the flawed internal report and the flawed initial external report. It has taken us almost two years to get an independent review. This should not be the responsibility of grieving parents to push for.

An external review cannot be deemed to be independent, like in our example. It will not provide the honesty and openness of the coroner’s court. It will not provide the follow through in learning to prevent other baby deaths.”