To ask the Scottish Government what immediate action it will take to address the reported failure by NHS boards to publish significant adverse event reviews related to mother and baby deaths in hospitals. (S6T-02503)

In February this year, Healthcare Improvement Scotland published its updated national framework for reviewing and learning from adverse events in NHS Scotland. National health service boards must operate within that robust national framework, which includes a template for sharing learning from adverse events locally and nationally. The Scottish perinatal network has facilitated tailored, cross-board learning opportunities following adverse events to share learning across the maternity and neonatal community.

The Scottish Government is currently meeting directly with leaders from all NHS boards as part of a programme of work to improve significant adverse event reviews. That programme includes on-going engagement with Healthcare Improvement Scotland on the renewed approach to reviews, and my officials will meet Healthcare Improvement Scotland on 15 May to discuss that important work.

I pay tribute to the Sunday Post journalist Marion Scott, whose outstanding public interest journalism has, once again, exposed failings that have had devastating consequences for families in Scotland.

We know that, despite the Scottish Information Commissioner saying that they can be published, more than 500 redacted significant adverse event reviews of the avoidable deaths of mothers and babies have not been published—not one. Those tragedies should have been investigated and learned from; instead, they have been hidden.

How on earth has that been allowed to happen under a Government that promised openness and accountability after previous scandals in maternity care? When exactly was the minister made aware of the widespread failure by NHS boards to publish those reports, and what did she do about that?

Any death of a mother or baby is a tragedy, and I extend my heartfelt sympathies and condolences to all who have experienced that trauma.

We have to recognise that the vast majority of public engagement with our national health service is positive, but we are certainly not complacent. I read the piece in the Sunday Post on Sunday. I understand from Healthcare Improvement Scotland that, in 2023, the Scottish Information Commissioner determined in response to a freedom of information request that individual SAERs were effectively part of the patient record and that NHS boards would be at risk of breaching patient confidentiality if they were to be published in full. However, as I highlighted in my first answer, the Scottish perinatal network has done a lot of work on the matter to ensure that patients, families and carers are at the centre of the review process and, importantly, to ensure the safety and psychological safety of staff.

I appreciate what the minister has said. However, we are not talking about the full reports; we are talking about the redacted reports. We are talking about children who have died, about mothers who have been lost and about families who have been left with no answers, no justice and no access to reports that should have been shared with them as a matter of basic human decency.

When a family that has lost a baby asks to see the review of what happened, is there any justification at all for refusing them that redacted information? Will the minister now say unequivocally that those reports must be published? Does she agree that there can be no place—none—for secrecy or defensiveness in our NHS, that families deserve the truth and that accountability is not an optional extra but the absolute minimum that we owe to those who have suffered the worst imaginable loss?

The SAER is a review that is carried out by experts into what went wrong and why. It is there to create a fuller picture of what happened and what changes need to be made as a result. SAERs are learning and system learning exercises that are incredibly important. The revised framework that was introduced by HIS includes a template for boards to use when reviewing SAERs. It also includes a new learning summary template that will be published on a new online community of practice once completed.

In addition to what the minister has described about actions in adverse event reviews, can she advise what updates the Scottish Government has had from health boards across the country regarding the steps that are being taken to sustain and enhance maternity services, including in Wigtownshire in the west of the NHS Dumfries and Galloway region?

On 6 February 2025, the Scottish Government published a suite of documents for implementation by NHS boards that were produced to support the aim of improving maternity and neonatal care in Scotland. They are the product of a co-development approach that has drawn on the expertise of our clinical and third sector partners. We are currently developing a robust process for monitoring progress towards implementation. A report will be published in the coming weeks that will summarise responses from all NHS boards on implementation of the recommendations in “The Best Start: A Five-Year Forward Plan for Maternity and Neonatal Care in Scotland”.

We knew about the concerns previously. Whistleblowers at NHS Lothian raised concerns about staff shortages at a maternity unit last year, and an investigation that was launched back in 2024 found that there has been a toxic relationship between managers and midwives. One midwife, who remained anonymous, spoke to STV News last year and said:

“Management didn’t listen to staff concerns—we’d say we’re short staffed and they’d say it was fine.”

I imagine that that will not be the only case of such relationships between managers and midwives in a health board. How do we correct that culture to improve relationships between managers and midwives and encourage whistleblowing, should there be concerns?

I welcome the apology from NHS Lothian to its maternity care staff following the report of the independent review of its women’s services. NHS Lothian has committed to working with staff in maternity services to ensure that they feel supported at work, safe to raise concerns and able to thrive. I expect NHS Lothian to take that work forward as a priority to ensure that that learning is translated promptly into action to improve staff experience at work, so that they are empowered to continue to deliver the best and safest care that is possible for mothers, their babies and their families.

I thank Stephen Kerr for raising a really important issue. I hope that the minister will have more to say about the issue—families deserve more. Does the minister feel that the Government has done enough to ensure that the shared learning from significant adverse events happens is shared with staff? If the families are not getting the details, how do we make sure that those things do not happen again? Our staff are also at risk.

I agree that we have to ensure that we get the right support for our staff who work in NHS maternity units. As I highlighted in one of my responses to Stephen Kerr, one key thing that the Scottish perinatal network highlighted was the importance of staff psychological safety. As I said in my response to Meghan Gallacher’s question, I very much support the work that NHS Lothian is doing to ensure that its staff get the right support to carry out their roles, which are incredibly important to all of us who live in Scotland.

It seems that the only answers that are available to the bereaved families at the heart of the issue are in the journalism of the Sunday Post . They are getting precious little from Scottish ministers and nothing from inside this chamber.

The minister will recall that, on two occasions last year, following a spike in neonatal deaths and adverse neonatal ward events in 2021 and 2022, I asked her to make Government time available to debate those findings. First, she said that she would look at that; secondly, she told me that there were no plans. Will she now, at the third time of asking, make parliamentary time available for consideration of those very concerning events?

I remember my previous conversations with Alex Cole-Hamilton. I am content to take that away.

That concludes topical question time. Before we move to the First Minister’s statement, I invite members to join me in welcoming to the gallery the honourable Pat Weir MP, speaker of the Legislative Assembly, the Parliament of Queensland. [ Applause .]