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It is a great privilege to speak from the Back Benches for the first time in over a decade following two extremely powerful speeches from both Front Benches. I thank the Minister of State and the shadow Minister for two extremely compassionate and understanding speeches in which they spoke about the sheer pain felt by so many families up and down the country.
I also thank the many hon. Members on all sides—my hon. Friends the Members for Eddisbury (Antoinette Sandbach), for Colchester (Will Quince) and for Banbury (Victoria Prentis), Mrs Hodgson and many others—who have spoken so powerfully on this matter. I cannot possibly compete with the power of their words because there is nothing that anyone can suffer more than the loss of a child. I just want to make one observation from my many years—some would say too many—as Health Secretary with respect to this issue, and that observation is about the impact on professionals.
When you go around hospitals up and down the country, and ask the doctors, nurses and midwives, “What is the most traumatic thing that has ever happened to you in your professional career?”, almost invariably they will say that it is when they lose a baby. We often talk about the trauma for the families, who of course are the primary victims in this situation, but we must never forget the people who are sometimes called the second victims: the doctors, nurses, midwives and other professionals who have to go home, worrying that if they had done something differently that baby might still be alive, and who have to come back to work the next day and struggle on, dealing with that incredible trauma.
In that situation, those professionals want nothing more than to be completely open, transparent and honest with the families and with their colleagues about what happened to ensure that lessons are learned and that that tragedy is never repeated again. But in the NHS today, we make that practically impossible. People are terrified of the Nursing and Midwifery Council, the General Medical Council, the Care Quality Commission and their trust. They are worried about being fired and they are worried about all sorts of consequences, so the one thing that should happen—the one thing that everyone in that situation wants to happen more than anything else, which is that lessons are learned from that tragedy—is often the one thing that never happens at all.
Let us remember that there are 1,400 neonatal deaths every year, as the shadow Minister said. That is about four every single day across the NHS. The great tragedy—not just in the NHS but in hospitals all over the world—is the fact that a tragedy can happen in Blackpool one day, and a month later exactly the same tragedy can happen in Cornwall. There has not been enough effort to try to share the learnings from such tragedies. I commend the efforts of the Government and my successor Ministers for doing everything they possibly can to put this right and to ensure that we really do become a learning organisation. In truth, though, this is a big job that will take a long time, because it is about changing culture.
The NHS needs to look at other industries that have successfully changed from having a blame culture to having a learning culture. The airline industry is the most famous example, but there are also the nuclear and oil industries. That job of changing culture will be our central responsibility if we are to reduce the agony for parents and the professionals involved in the care of babies. The most powerful way to change culture is to shout out loud and clear those human stories of the terrible loss involved, because that is what promotes change.
I finish by commending everyone involved in Baby Loss Awareness Week—the brave Members of this House who have spoken out, and given many others hope that they are not alone; the many brave members of the public who have relived their own tragedies over and over again to try to promote change in this area; and the Ministers concerned, who have a heavy responsibility when it comes to this agenda, and who I know take that responsibility with the utmost seriousness.