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Ockenden Review
10 December 2020
Lead MP
Nadine Dorries
Debate Type
Ministerial Statement
Tags
NHSEmploymentParliamentary Procedure
Other Contributors: 15
At a Glance
Nadine Dorries raised concerns about ockenden review in the House of Commons. A government minister responded. Other MPs also contributed.
How the Debate Unfolded
MPs spoke in turn to share their views and ask questions. Here's what each person said:
Government Statement
Madam Deputy Speaker, with permission I made a statement regarding the initial report from the Ockenden review, established in response to concerns raised by bereaved families. The inquiry, led by Donna Ockenden, reviewed 1,862 cases, initially covering 23 but expanding due to additional family reports and identified extra cases post-launch. This interim report of a two-part series details serious failings in the trust's maternity services from 2000-2018. The minister expressed profound sympathies for affected families and thanked them for their cooperation despite the pain involved. Key findings were presented, including critical actions to improve safety and patient care across all levels. Recommendations cover areas such as maternal deaths, obstetric anaesthesia, neonatal services, enhanced patient safety measures, staff training, complex pregnancy management, risk assessments, fetal wellbeing monitoring, and informed consent provision. The trust has accepted these recommendations. The minister affirmed the government's commitment to improving NHS maternity service safety, aiming to halve stillbirths, neonatal, and maternal deaths rates by 2025 compared to 2010 levels.
Justin Madders
Lab
Ellesmere Port and Bromborough
Question
The shadow minister asked about support for families who have come forward to share their experiences, resources allocated for completing the final report, deadlines for implementing system-wide recommendations, updates on progress, reinstatement of the NHS maternity safety training fund, addressing staffing shortages, ensuring safe staffing levels through legislation, tackling bullying in hospitals, and reassuring current patients at the trust.
Minister reply
The minister stated that families who have come forward will receive appropriate support. She assured that the review has sufficient resources but did not specify a deadline for completing the final report. The minister committed to regular updates on progress with system-wide recommendations. She indicated reinstating the NHS maternity safety training fund and addressing midwife shortages, though she did not commit to legislating safe staffing levels or tackling bullying in hospitals specifically.
Justin Madders
Lab
Ellesmere Port and Bromborough
Question
Thanking the minister for her statement, highlights systemic issues within NHS regarding openness and transparency when things go wrong. Expresses appreciation of families' persistence in seeking answers and support for them to deal with consequences. Inquires about resource availability for Ockenden review, urgency of system-wide recommendations implementation, deadline setting, and updates provision.
Minister reply
Acknowledges the constructive tone and assures resources are guaranteed. Report will be completed by end of next year. £9.4 million secured in spending review to fund training but not in old format due to inefficacy. Recruitments for new nurses (including midwives) underway.
Jeremy Hunt
Con
Godalming and Ash
Question
Questions about caesarean section rates, judicious use of oxytocin, and the blame culture in NHS. Highlights the need to stamp out 'normal birth' ideology which compromises babies’ safety.
Minister reply
Acknowledges the issue with low C-section rates compared to national average indicating lack of communication between medics. Emphasises the importance of patient control over their delivery plans. The NHS is developing an early warning surveillance system to monitor such issues and ensure strict adherence to NICE guidelines on oxytocin use.
Wera Hobhouse
Lib Dem
Bath
Question
Expresses sympathy for those affected by tragic events, asks the Minister to ensure that training in perinatal mental health becomes a focus of improving maternity services.
Minister reply
Acknowledges the importance of post-natal depression services rolled out across the UK and agrees to take Hobhouse's point on board.
Question
Compliments the Minister for promptness in making the statement, praises Jeremy Hunt for initiating the review, expresses concern about the delay in implementing Ockenden report recommendations.
Minister reply
Thanking Allan for her persistence and dedication, assures that she will drive forward the implementation of the report's findings.
Jim Shannon
DUP
Strangford
Question
Expresses sympathy for affected families, asks the Minister to guarantee UK-wide review procedures to implement Ockenden report recommendations.
Minister reply
Cites progress made in implementing Morecambe Bay trust investigation recommendations and assures that steps will be taken for consistent implementation of findings.
Question
Expresses sympathy, thanks Donna Ockenden and her team for their work, asks about improvements in safety and standards at Shrewsbury and Telford Hospital NHS Trust.
Minister reply
Thanks Dunne for his question, assures that recommendations from the report are being discussed and implemented within the trust.
Tan Dhesi
Lab
Slough
Question
Discusses other maternity scandals since Morecambe Bay, asks about steps taken by the Government to implement findings of inquiries.
Minister reply
Cites progress made in implementing Morecambe Bay recommendations and discusses development of a core curriculum for multi-disciplinary training.
Daniel Poulter
Con
Surbiton
Question
I welcome the considered tone the Minister has taken today in responding to the difficult contents of this report and in promoting a clinically led response to the findings rather than allowing knee-jerk political reactions that often do not lead to the right results. Let me pick up on one thing. What we see throughout a number of reports, be it Mid Staffs, Morecambe Bay or now this one, is that management is often central to setting a culture that allows mistakes and deaths to occur. When a clinician is found to be negligent, they have a responsible body—the Nursing and Midwifery Council or the General Medical Council—that can take action against them, but what are we going to do to ensure that managers receive better training and that we stop the revolving door of bad managers who are responsible for poor care being employed elsewhere in the NHS?
Minister reply
I thank my hon. Friend, who, again, is a predecessor in my Department—a former Health Minister. He is absolutely right to talk about strong leadership. Strong leadership has been established across the system. In terms of the management of the Shrewsbury and Telford trust, there have been eight chief executives in 10 years. That is not good. Good practice does not come from a revolving door of chief executives and board members who constantly rotate, because there is no continuation of learning, no loyalty, and no commitment to good outcomes at the hospital. We have to change this revolving door of boards and chief executives.
Liz Twist
Lab
Blaydon and Consett
Question
First, our thoughts today must be with all the families who have been affected by this tragedy. The investigation found that an area of concern was having the right staffing levels and the right skills mix. Will the Government look to legislate for safe staffing levels in the NHS and, in particular, midwifery?
Minister reply
It is probably in the Secretary of State’s domain to make that kind of statement at the Dispatch Box, so I cannot give the hon. Lady that reassurance myself, but we are delighted about the huge number of new nurses and doctors that we have in training. Recruitment of our workforce in the NHS is going well, and I hope that that will be the ultimate goal.
Dean Russell
Con
Watford
Question
Reading this report is utterly heartbreaking, and my heart goes out to the families who have been involved in this terrible situation. Leadership, workplace culture and patient safety clearly go hand in hand, so what steps is my hon. Friend taking to strengthen clinical leadership, in order to ensure that all maternity wards are the safest they can be?
Minister reply
I pay tribute to my hon. Friend for not only his work at Watford General Hospital—he is probably there more often some of the patients—but his commitment to mental health in his constituency. He has launched a programme of 1,000 mental health first aiders, which is a tremendous boost to his constituents.
Rachael Maskell
Lab/Co-op
York Central
Question
It is devastating to read about the families involved in this. We have been here so many times. I think back to the publication of the Robert Francis report in 2013, which particularly talked about the duty of candour and the way that those issues are addressed. Clearly the system is quite passive; it is dependent on people raising concerns. What is the Minister doing to ensure that it is more interrogative of families and those involved in order to draw out people’s concerns at what is perhaps their most vulnerable time, as is the case for many women when giving birth?
Minister reply
The hon. Lady is right: there is a theme. Whether it is Paterson, the Cumberlege review or Morecambe Bay, central to all this is women, and so much of this report is familiar in that women are not listened to. The way some of those mothers were spoken to when they were delivering their babies or during the most tragic hours and days afterwards is just appalling.
Robert Halfon
Con
Harlow
Question
My heart goes out to the families. I pay tribute to the Minister for her work on this. Although these tragic things go wrong in our national health service, does my hon. Friend note that many good things also happen across our hospitals? Our maternity ward in the Princess Alexandra Hospital in Harlow has been described as “outstanding” by the Care Quality Commission, and is one of the most successful and important parts of our hospital. Will she pay tribute to and thank staff across the NHS, as well as in Harlow, who do so much? Will she also look at best practice around the country, in places like the Princess Alexandra Hospital for maternity, to see what can be done to learn from that best practice to ensure that such tragedies never happen again?
Minister reply
My right hon. Friend adds such a hopeful note. I thank him. He is absolutely right. We stand here to talk about reports, patient safety issues and where things have gone wrong, and yet so much of the NHS so much of the time goes absolutely right.
Kerry McCarthy
Lab
Bristol East
Question
In that case, I thank the Minister for what is clearly a very genuine response to the concerns expressed today. What has been said about the culture within the NHS, revealed in this review, has echoes of the Bristol heart babies scandal, and it is tragic that parents must still fight to have their voices heard now. One of the things mentioned by families contributing to the Ockenden review is the desperate need for longer-term support following experience of baby loss. I know from my constituents that the NHS has struggled to provide that during the current pandemic. What more can we do to ensure not just that parents are listened to at the time of losing their baby, but that they are supported from then onwards, too?
Minister reply
I thank the hon. Lady for her comments, sincerely, and for her important question. Baby loss is something that we discuss in this House—rightly so—and we are discussing what happened at Shrewsbury and Telford, because many parents there lost their babies. The report makes a recommendation that the care and support that parents are given following a bereavement are strengthened, and that measures are put in place to ensure that the right package is there.
Shadow Comment
Justin Madders
Shadow Comment
The shadow minister acknowledged the statement's importance but criticised systemic cultural failings in NHS maternity services highlighted by the report. He emphasised the need for senior leadership to address these issues openly, taking responsibility rather than defensiveness when things go wrong. Madders praised families' persistence despite unimaginable suffering and stressed the need for appropriate support for them. He also questioned whether the review has adequate resources to complete its final report swiftly and called on the minister to set deadlines for implementing system-wide recommendations with updates provided regularly. The shadow urged reinstatement of the NHS maternity safety training fund, addressing midwife shortages, ensuring safe staffing levels through legislation, and tackling bullying in hospitals. Finally, he sought reassurance for families currently receiving care at the trust.
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