Reducing Baby Loss — [James Gray in the Chair]

Part of the debate – in Westminster Hall at 9:46 am on 20th July 2021.

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Photo of Lilian Greenwood Lilian Greenwood Opposition Deputy Chief Whip (Commons) 9:46 am, 20th July 2021

I would like to focus on the progress towards safe births at my local trust. I wish I did not need to speak in this debate; I wish that Nottingham’s hospitals, Queen’s Medical Centre and Nottingham City Hospital, were safe places to have a baby. That is what parents in my constituency need and have a right to expect. But right now, that is not what they are guaranteed, as the trust’s chief executive admitted a few weeks ago:

“We fully accept that, although our staff are passionate about what they do, we have not created an environment where these same staff can provide a positive and safe experience for every family in their care, every time.”

A recent investigation by The Independent and “Channel 4 News” found that since 2010, there have been 201 clinical negligence claims against the trust’s maternity services—almost half lodged in the past four years. In those claims are 15 deaths, 19 stillbirths, 46 cases of brain damage and 18 cases of cerebral palsy. The trust has already paid out £79.3 million in compensation but, of course, the human costs are much higher.

In September 2019, Wynter Sophia Andrews was born at the QMC. She died 23 minutes later. It was only after the healthcare safety investigation branch’s findings were published that the trust admitted failings and that earlier intervention would have avoided Wynter’s death. Wynter’s death was the subject of an inquest, and in her verdict the coroner was highly critical of Nottingham University Hospitals NHS Trust. The coroner said that Wynter would have survived if action had been taken sooner. I will not read the detailed quote from the coroner, but she said that the incident reports and staff accounts demonstrate that

“this was not an isolated incident. An unsafe culture had been allowed to develop as these systemic issues had not been adequately addressed by the leadership team.”

During the inquest, it also emerged that a letter from maternity staff at the trust was sent to the hospital board in 2018 asking for help and raising serious concerns about safety.

Following the coroner’s report, NUH maternity services were subject to unannounced inspections by the Care Quality Commission, which published its report last December. The inspector said:

“During the inspections, several serious concerns were identified. For example, risk assessments which women were expected to have undertaken during their care were not always completed in line with national guidance. Staff did not always use a nationally recognised tool to identify women at risk of deterioration. n addition, the service did not always have enough midwifery staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix but were limited to the resources available. Following this inspection, maternity services at Nottingham City Hospital and Queen’s Medical Centre are rated Inadequate overall. The services are rated Inadequate for being safe, effective and well-led. Maternity services were previously rated Requires Improvement.”

The worst thing about the situation is that it did not need to be like this. When I read Gary and Sarah Andrews’s account of Wynter’s death, I felt sick—not just because it is tragic and heart-breaking for anyone to lose a much wanted baby, but because there were striking similarities to an earlier case.

My constituents Jack and Sarah Hawkins’s daughter was born dead at Nottingham City Hospital in April 2016. Harriet was a healthy, full-term baby. She died as a result of a mismanaged labour. The trust initially claimed that her death was caused by an infection. Jack and Sarah were told to “try to move on.” It was only thanks to their incredible courage and determination to fight for the truth that the trust was finally forced to admit gross negligence.

I sat with Jack and Sarah in a meeting with the trust’s then chief executive, with photos of Jack, Sarah and their dead daughter on the table in front of us. He apologised and promised that the trust would learn the lesson. Following the coroner’s verdict in Wynter Andrews’s case, I read the comments from senior staff at the trust, apologising and promising to learn the lessons. They were the exact same promises that I had heard more than three years earlier.

Gary and Sarah Andrews wrote to me in March. They said:

“All we want is for other parents to be taking their children home.”

They, Jack, Sarah and other parents are calling for a public inquiry into maternity services at Nottingham University Hospital Trust. I am sure that the Minister will tell me, and them, to put their faith in the Care Quality Commission and the Healthcare Safety Investigation Branch, but they do not share her confidence that that will be effective. In Harriet’s case, there were numerous investigations, both internal and external, but things did not change or did not change enough.

As the Health and Social Care Committee report notes,

“Involving families…is a crucial part of the investigation process…Families must be confident that their voices are heard and that lessons have been learnt to prevent the tragedy they have endured being repeated.”

When I met the CQC investigation team in April, I was shocked to hear that they have not contacted bereaved parents or sought to hear their views. They claimed to be unaware of Harriet Hawkins’s case.

When I raised concerns with the Minister, her reply contained the news that NHS England, NHS Improvement and the clinical commissioning group are

“finalising the terms of reference for an independent thematic review of maternity cases going back to 2016”.

As Jack Hawkins told me, this has happened without any input from families. The review was due to go back to only 2016, although we know there were many improperly investigated baby deaths and harmed babies before then. That is why they want a truly independent review, not one where it is too easy to suggest that Nottingham University Hospital Trust has a hand in it, and where parents of dead and damaged babies are ignored and excluded from the process of deciding what needs looking at.

I hope that when the Minister meets me and other MPs she will also hear from the parents affected by some of these tragic failures to improve maternity services at Nottingham University Hospital Trust. I look forward to hearing her response both today and on that occasion.