(1 day, 11 hours ago)
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Madam Deputy Speaker (Caroline Nokes)
I call Andy MacNae, who will speak for about 15 minutes.
Andy MacNae (Rossendale and Darwen) (Lab)
I beg to move,
That this House has considered baby loss.
I am deeply privileged to be opening this debate in the middle of national Baby Loss Awareness Week, and in advance of the international “wave of light” on Wednesday. I want to start by welcoming the bereaved families who have joined us in the Galleries, and particularly for doing so at such a late hour: they have shown fantastic stamina in sitting through some fascinating business. I know that a number are also watching online. I have no doubt this will, for many of us, be an emotive debate that will bring back many memories, so I say this to those in the Galleries: I am grateful for your courage in joining us, and your presence lifts this whole debate and this whole day. I know that for many of you, your story is one of being let down by the system. While today cannot undo that, I hope that this national spotlight on what you have experienced, and our shared commitment to fundamental change, will be of some comfort. I also thank everyone in the Chamber for their attendance today, and for the cross-party support that the debate has received.
This is a personal topic for me and for my family. Our daughter Mallorie was born in 2015 with Edwards’ syndrome, a condition that we were told was not compatible with life; yet she lived for five days, and died in my arms. Those days were both the hardest of our lives and the time that we value most. We spent those days in the butterfly suite, a bereavement room funded by the local baby loss charity Friends of Serenity. Throughout that time, we received amazing support from the maternity team at Burnley hospital. I want to take this opportunity to thank, once again, all the team at Burnley, and to recognise the amazing work that baby loss charities do throughout the UK.
The years since Mallorie’s death have been challenging. The impacts of losing a child do not end after a week or a month or a year; they stay with us. My wife, Vanessa, suffered depression and post-traumatic stress disorder following Mallorie’s death, and has never been able to fully recover and return to her work as a health visitor. For 10 years she has had consistent difficulties in accessing sustained specialist mental health support, instead being bounced between short-term interventions and generalists. Her NHS career has now been terminated on grounds of ill health, and she is back on a five-month waiting list for therapy. Yet we count ourselves among the lucky ones. We had as good a hospital experience as we could have had in the circumstances, and time to prepare for what we knew was an inevitable outcome. We did not leave feeling that more could have been done, or that we had been let down; we felt listened to and supported in the weeks that followed.
Sadly, however, as we will hear today, far, far too many families have had the very opposite of that experience. We will hear heartbreaking accounts of babies who should not have died, of families’ concerns being belittled and ignored, of practices that fall well below any acceptable standard, and of institutional cultures of denial and cover-up. I believe that as we reach the end of today’s debate, no one will be in any doubt that addressing the long-term systemic failings in maternity care once and for all must be an imperative for this Government.
Let me start by detailing the extent of this challenge. Tragically, 13 babies die shortly before, during or soon after birth every day. Every day, 13 mothers know the immense grief of losing a child they were expecting to welcome into their lives. In 2023, there were 4,478 baby deaths in total. Some 1,933 of these were neonatal deaths, while 2,545 were stillbirths, with the cause of one third of those stillbirths still unknown. More broadly, ectopic pregnancy affects one in 80, while 240 infants die every year from sudden unexplained death syndrome, and evidence suggests that one in six pregnancies in the UK ends in miscarriage.
Crucially, these family tragedies are not shared equally throughout society; ethnic minorities and those living in deprivation are far more likely to experience this loss. This has been known for 70 years, yet little action has been taken to address it. Even in 2023, black babies were over twice as likely to be stillborn compared with white babies, while neonatal mortality rates among black and Asian babies were over one and a half times higher than the rate among white babies. Similarly, babies born to mothers living in the most deprived areas are twice as likely to die shortly after birth than those in the least deprived areas. This profound inequality must be rooted out.
These deaths occur amid a pattern of poor culture and practice in too many of our maternity wards and trusts. In its 2022 to 2024 review, the Care Quality Commission found that only 35% of maternity units were rated as “good” for safety. No units were found to be “outstanding”, and 65% were rated “inadequate” or “requires improvement”. Behind these figures lies a litany of family tragedy. In response, there has been no shortage of inquiries. Over the last 10 years, we have seen reviews or investigations into care in East Kent, Morecambe Bay, and Shrewsbury and Telford, as well as the ongoing review in Nottingham. These have revealed much and made many recommendations, yet change has not come and the cycle of failure has continued.
It is in this context that the Government have rightly decided to launch a national investigation—a systematic and urgent national review of maternity services. This is an opportunity that we must grasp, and we have a Secretary of State who I believe truly understands the urgency and importance of making it count. We have the investigation being led by a chair of the highest reputation, we have a commitment to a taskforce to deliver on recommendations, and we have many colleagues in this place who are determined to make sure that the voices of families are heard and acted on.
We must get this right, so before I hand over to colleagues, I would like to make four key asks. First, the investigation must provide clear and binding steps to achieve national change in maternity care, particularly to tackle the inequality of outcomes that is dependent on the race or wealth of the mother. To this end, the investigation must set out clear, consistent approaches to safety across all maternity units in England, which means unequivocally defining “safety”—amazingly, there is no shared definition of “safety” across maternity services. The inquiry must identify the reasons why past recommendations have not been implemented or resulted in change. It must be willing to address any embedded cultural, structural or governance factors that undermine quality, safety and accountability. When the investigation reports and the taskforce releases its action plan, the Government must fully resource the delivery and ensure there is robust monitoring and real accountability.
Secondly, it is crucial that the Government set new national maternity safety ambitions. In 2015, the then Government announced ambitions to halve relative rates of stillbirth, neonatal deaths, maternal deaths and brain injuries by 2025. Alongside that, they also announced an ambition to reduce preterm births from 8% to 6%. Those ambitions are due to expire and, in any case, were never on track to being met. It is a stark reminder of how important this issue is that 2,500 fewer babies would have died if the targets had been reached.
The UK’s baby death rate is still considerably worse than those of the best-performing countries in Europe. To match those countries, Sands and Tommy’s have proposed new ambitions, with an end date of 2035 to align with the NHS 10-year plan. I apologise for the list, but they include a stillbirth rate of two per 1,000 total births; a neonatal mortality rate of 0.5 per 1,000 live births for babies born at 24 weeks’ gestation and over; a preterm birth rate of 6%, with disaggregated data for iatrogenic and spontaneous preterm births; and eliminating inequalities in these outcomes based on ethnicity and deprivation.
The Government’s commitment to close the black and Asian maternal mortality gap is welcome, but it must explicitly include closing the black and Asian stillbirth and neonatal mortality gaps. Establishing routine data collection on miscarriages should be prioritised. Once that is established, an ambition to reduce the miscarriage rate should be added. I urge the Government to be ambitious, and to implement these new targets, which will help to guide and inform the improvements that will be made in services in the years to come.
Thirdly, we must urgently improve bereavement care for parents in hospitals and the mental health support they receive after discharge. Losing a child is devastating, and compassionate care, both immediately and in the long term, is vital to processing grief. The national bereavement care pathway aims to standardise bereavement care, and states that this should be given by trained staff, with dedicated grieving spaces provided, opportunities for parents to have meaningful moments with their baby offered and referrals for further support made.
Since its 2017 launch, NHS trusts have gradually adopted the pathway, with full coverage achieved in 2024. However, voluntary uptake and a lack of ringfenced funding have led to highly inconsistent implementation, and sometimes it is entirely lacking. A bereaved mother described the hospital support she received as:
“Terrible. No aftercare whatsoever. I felt abandoned. My mental health spiralled due to lack of support and not knowing where to get help… I left that hospital with a broken heart.”
Bereavement support must continue post discharge. I have described the challenges that my wife Vanessa has faced in accessing specialist support, and she is by no means alone. Sands’ 2025 report found that over 80% of bereaved parents needed specialist psychological support post discharge, yet despite the introduction of NHS maternal mental health services in England, only 17% of bereaved parents were actually able to access it.
We must also recognise the additional barriers that fathers and partners face in accessing support. Only 29% of services offered basic assessments to fathers in 2024, and those are often quite perfunctory. One father explained how he was assessed and recommended for psychological interventions and a referral to a clinic, yet the only support he actually received was a leaflet outlining local self-help groups. It is not good enough, and services must recognise that fathers and partners also grieve. So I urge the Government to issue clear standards and national guidance for commissioning specialist mental health support services for bereaved parents, including fathers and partners.
Support must also be given to healthcare professionals, who can themselves be impacted by baby deaths. Training remains inaccessible for many healthcare professionals, and staff often lack the time to attend sessions. Bereavement care training must be available during work hours, and overall we must ensure staff are equipped to support grieving families and to look after themselves.
Finally, I want to touch briefly on the role of regulators, most notably the Nursing and Midwifery Council. In an area as critical as maternity safety, an effective and accountable regulator is a crucial component, yet issues with the NMC are long term and well documented. As was noted in relation to the 2024 culture review of the organisation:
“Good nurses are finding themselves being investigated for years over minor issues and bad nurses are escaping sanction because of a system that’s not functioning as well as it should.”
Such failures can have tragic consequences. For instance, the NMC cleared a midwife who had been referred to it following the avoidable death of a baby in Morecambe Bay in 2008. In 2016, the same midwife was linked to the death of another baby, and subsequently dismissed by their trust for actions fundamentally below acceptable standards. This cannot continue, and if we are to deliver on our maternity safety ambitions, we need an effective, culturally healthy regulator. The NMC still has a long way to go until it could contribute in this way. The Government must continue to offer rigorous scrutiny, demanding accountability and ensuring that the NMC becomes the regulator that nurses and midwives, as well as the public as a whole, deserve.
To sum up, each year babies die who should not have died, every year mothers are failed and harmed, and every year parents experience profound loss without the support to deal with it. We cannot continue as we are. We have both an opportunity and an obligation to act. This Government have the chance to drive a change that will be felt in the lives of families for generations. To do this, we must deliver on the full potential of a national investigation. Clear, impactful and binding actions must address systemic weaknesses and embedded cultures. To ensure long-term focus, we must also adopt ambitious, measurable targets to align with the NHS 10-year plan.
These steps to reduce baby loss must come in tandem with a compassionate system of care for those who do experience loss despite our best efforts. To this end, the Government should issue national guidance on commissioning specialist mental health services for bereaved parents. Finally, the Government must ensure the sector has capable and accountable regulators to ensure that professional standards are maintained. Taken together, we can make what has been a story of national tragedy into one of national pride, delivering compassionate and exemplary care for women and babies when they need it most. This is the challenge and the opportunity before us, and we must not fall short.
Sir Jeremy Hunt (Godalming and Ash) (Con)
It is a great privilege to follow the hon. Member for Rossendale and Darwen (Andy MacNae). I thank him for working with me and the hon. Member for Sherwood Forest (Michelle Welsh) to secure the debate, and I thank my many colleagues on the all-party parliamentary group on patient safety. I would also like to thank the Secretary of State for Health and Social Care, the right hon. Member for Ilford North (Wes Streeting), for being here himself today. It means an enormous amount to families up and down the country to see that commitment from him. I know it is an issue in which he has taken enormous personal interest.
I think the most difficult meeting I had when I was doing his job many years ago was with a man called Carl Hendrickson, who came to see me a few days before I stood at that Dispatch Box to give the statement on the Morecambe Bay inquiry. Carl lost both his wife and his son at Morecambe Bay NHS Foundation Trust. A midwife mistook some fitting by his wife as just fainting. His wife died an hour later from an embolism. The next day, his son Chester died from brain damage. He came to see me with his 11-year-old son, Conrad. I will never forget it, because it was obviously going to be a very difficult meeting and I asked him whether he would like his son to sit outside with some of the civil servants while we discussed what happened. He said no, because he wanted his son to know, for the rest of his life, that he had taken his concerns about what went wrong right to the very top and asked awkward questions. And that was what he did.
I owe a great debt to the Morecambe Bay families: to Carl and to Simon Davey, Liza Brady, James Titcombe and many others. The American thinker Margaret Mead had a saying:
“Never doubt that a small group of thoughtful committed individuals can change the world; indeed, it’s the only thing that ever has.”
For me, those Morecambe Bay families were that small group of thoughtful, committed people, along with the families from Mid Staffs, Shrewsbury and Telford, East Kent, Nottingham and many other places.
As we reflect in this very sad and meaningful Baby Loss Awareness Week about what has gone wrong, it is also important to remember that progress has been made since then. Since the Morecambe Bay inquiry, the overall number of baby deaths is down by about 20%. That is about 700 fewer a year, or two fewer a day. The NHS is better than it was about being honest about mistakes. There have been a lot of reforms. We have a chief inspector of hospitals and a CQC that is set up to call a spade a spade when there is poor care. We have the duty of candour, which will be further strengthened by the new Hillsborough law. We have medical examiners, we have Martha’s rule and we have “freedom to speak up” guardians.
Despite those improvements, there are some warning signs. Since the pandemic, the decline in baby deaths has plateaued. The number of maternal deaths has actually increased. As the hon. Member for Rossendale and Darwen just said, there is big inequality. You are far more likely to die as a black or Asian mum. You are far more likely to die as a black or Asian baby, or a baby from a deprived background, than other babies. Still we have a third of NHS staff, according to the staff survey last year, saying that they are afraid to raise safety concerns, and half saying that they do not think anything will happen if they do.
The thing that is so important to remember—I have said this to the House on many occasions—is that if you are in a birthing unit and present at a C-section and something goes wrong, there is nothing as a professional that you want more than to be open, honest and transparent about what happened, so that lessons can be learned and you can make sure that mistake never happens again. But our system makes that practically impossible. We have the CQC, the NMC, the General Medical Council and the trust. Lawyers get involved and people worry. There is jeopardy for clinicians: that if they are honest and open about the ordinary human mistakes that anyone can make, they will be punished for it. The result is that the one thing that needs to happen more than anything else—truthfulness to the bereaved families and learning the lessons so that the tragedy is not repeated—can be the very thing that does not happen at all. Instead, we get a five-year legal process happening and the truth is not established for maybe five, six or seven years after that.
So what needs to happen to put it right? We all have our lists of things, and I echo absolutely everything that was said in the wonderful speech before mine. For me, first of all, it is absolutely essential that we get the CQC back on its feet. It went badly wrong, but under new leadership that the Secretary of State has put in place, I believe it is now going in absolutely the right direction. We must return to the one-word ratings so that parents and families know absolutely whether the care in their local hospital or NHS organisation is safe. That is really important.
Secondly, we have a litigation culture. At the moment we spend about £3.5 billion annually in maternity awards for where maternity care has gone wrong, which is not far off the £4 billion total cost of all NHS maternity units. It has gone so badly wrong that many parents think that when something goes wrong, their only friend is not a doctor but a lawyer—that cannot be right. We need to have much better accountability. The Government are rightly absolutely committed to bringing back family doctors. People having their own GP would make an enormous difference, because at the moment there is no one inside the NHS to turn to when these things go wrong, and going back to the system of everyone having their own GP could make a really big difference to that.
We need to support the work of brilliant charities such as Tommy’s, Sands, the Clinical Human Factors Group and Baby Lifeline in their contribution to making maternity care safer. We also need to tackle the dangerous culture of “normal” births, which still sees too many mothers steered away from getting a surgical intervention when that would be the safest route for them and their baby. Those are all important changes.
I would like to say one final thing, which is that we must not return to a targets culture. I have some concerns about the new NHS league tables. I know they are set up with the best of intentions, but safety and quality is not one of the factors that ensures a move up the list. I know the Secretary of State will take great care in the way that those are implemented, but I think it is really important that there is always a bottom line—a floor—on safety and quality below which the system never goes.
What I really want to say to the House, in conclusion, is that we must not lose hope. If we had the same levels of maternity safety as Sweden, one fewer baby would die every day; if we got to the same levels as Japan, two fewer babies would die every day. If we could get the NHS back on the trajectory it was on in the years leading up to the pandemic, we would be able to get to care as safe as Sweden’s in the next five or six years, so it really is something within our grasp.
I will finish by saying this. The NHS was set up on the premise of equality, and the idea that no matter who we are—whether we are rich or poor, young or old, from the north or the south, from the city or the country—everyone should be able to access the healthcare they need. Everyone means every baby, too. We talk about safety more than any other healthcare system in the world. In this very sad week, when we remember all the people who have lost their dear babies and their dear loved ones in the process of having babies, let us redouble our efforts to make the NHS the safest, highest-quality healthcare system in the world.
Several hon. Members rose—
Madam Deputy Speaker (Caroline Nokes)
Order. I will now call the next co-sponsor of the debate. After she has spoken, there will be a five-minute time limit.
Michelle Welsh (Sherwood Forest) (Lab)
As a harmed mother from Nottinghamshire, I gave birth to my son by emergency C-section because health professionals treated me with utter contempt, ignored me and did not do as they should, and then said it was all my fault. My son was not put in my arms when he was born; instead, he was rushed over to a consultant to start him breathing. While I wish I had time to share the details of what happened in the Chamber so that others can understand the severity of a failing system, time does not permit me.
To those who have lost a baby, we know that when the world says, “I’m sorry for your loss”, it sounds thin and distant, because what was lost was not just a child. Families have lost first breaths, first steps, first days of school, and a lifetime of “I love you.” They have lost hope.
We must stop whispering about baby loss in the shadows. We must speak about the preventable errors, missed opportunities and systemic failures in our maternity services that have turned dreams into dust. Grief is a fact, but these failures are not inevitable. For too long the grief of affected families has been treated as a private sorrow and an isolated tragedy, but let me be clear: these are not isolated incidents. The heartbreak and loss are a consequence of a system that is failing, where warnings are missed, staffing is insufficient, preventable errors steal precious futures, tragedies are swept under the carpet and families have to fight for answers.
We have heard the data and read the reports, and we have shared our devastating stories. We know the truth: maternity services are fundamentally broken and our babies are paying the price. I am not asking for a miracle, but I am demanding competence, safety and accountability, and a country where every mother who walks into a delivery room knows that she is in the safest hands possible and that her baby will be protected. Our children deserve that safety, and the children yet to come deserve it too.
While we cannot bring back the precious babies we lost, we can honour their memory by ensuring that their fate is never repeated. We are not just mourning a past but fighting for a future where safety is guaranteed, where every mother is heard and where every birth is met with the excellence and dedication it deserves. Let the memory of the children we hold in our hearts be the light that guides our resolve. Let the stories be the steel in our spine. We pledge to them and ourselves that we will fix maternity services and build a legacy of safety so powerful that their short lives will forever protect the long lives of others, and we will do it for good.
I know from my own experience as a harmed mother in Nottinghamshire that speaking out and sharing what are potentially the most traumatic and personal experiences can be terrifying, and I want to commend those who have spoken out publicly and the hundreds of families who have spoken to me about their experiences. From talking to thousands of women and families, I have seen the recurring issues within our maternity services, including a culture of women not being listened to, a lack of accountability and situations where babies have died in the most horrendous circumstances and families are having to fight over and over again for answers and to relive the worst moments of their lives over and over again because the systems in this country are quite frankly broken.
I was the first elected member in Nottinghamshire to call for an independent review into maternity services at Nottingham University Hospitals NHS trust back in 2020. I am immensely grateful to the families, some of whom are in the Gallery today, who are leading the fight for change in Nottingham. We know that almost one in five stillbirths and neonatal deaths in this country could have been prevented through better care, yet the previous Government failed to act on this crisis, and families across the country have suffered immensely as a consequence. If I hear one more time that a previous Government Minister stood up and said that they were going to do it—well, they did not. They did not assign funding to it. They gave false promises to women and babies. We have a real opportunity under this Government to make maternity safer. Every woman deserves a birth experience where she feels heard, respected and, above all, safe.
Let me also be clear that this should never be an argument about natural versus surgical; it should be about what is the safest option for each woman. For too long the narrative has been poisoned by judgment. We have seen a damaging trend of labelling C-sections as a failure, a shortcut or a lesser way to give birth. The judgment is not just unfair but dangerous. The pressure created by this toxic conversation can sometimes push clinicians to delay necessary, lifesaving procedures or make women feel immense guilt for a safe outcome. Let us be clear that the safest birth is the most informed birth.
We must ensure that every woman has access to high-quality education regarding birth and feels confident asking critical questions about their care. We need to create a space where asking for help is seen not as a weakness but as a commitment to their wellbeing and their baby’s health. We must empower and support doctors, midwives and nurses, so that they can make decisions purely on medical necessity and safety—decisions that are free from dangerous judgments, including regarding C-sections. That requires us to have a workforce in place, so that clinicians can do their job, can make time for training, and, most importantly, once again have time to listen.
A key part of the conversation is continuity of care. We must ensure that midwives are given time to fully understand each woman’s needs and wants. By doing so, we can reduce the number of instances in which potentially life-threatening issues are missed and women fall through the cracks. Continuity of care can help address disparities in maternity care. When women—particularly black, Asian and minority women—see the same midwife throughout their pregnancy, they can build a relationship and ensure that their experience, culture and religious needs are considered. That creates a safer place for women to discuss sensitive issues and removes the frustration of having to repeat their story to numerous staff. If we can rebalance the conversations and culture around birth and put in place a system that allows for continuity of care, we can reduce the harm done to babies and families.
Continuity of care after birth will also be vital in reducing the incidence of death just after birth, which disproportionately affects babies born to mothers living in the most deprived areas of the UK; they are twice as likely to die in their first month as babies born to mothers in the least deprived areas. Change is so desperately needed. That is what families need, and what they are calling for. It is time to listen to the bereaved, and to harmed families, and to put them at the heart of any reforms.
Mr Luke Charters (York Outer) (Lab)
I thank my hon. Friend for making such a moving speech; she is an inspirational mum, raising awareness of this. If she will allow, I will raise the case of Hayley Patrick-Copeland, a bereaved mum who has been raising awareness of baby loss and putting in place support for bereaved parents. If I may, I will also put on the record in this place, for centuries to come, the names of her children, Alya and Aleah, whom she lost. Will my hon. Friend join me in remembering them, and in commending Hayley for her inspirational work, just like my hon. Friend’s, raising awareness of baby loss?
Michelle Welsh
I thank my hon. Friend; that was an important thing to say.
I was so pleased when the Secretary of State for Health and Social Care announced a rapid review of maternity services, which I believe he did to ensure that we get on with fixing the problems that we know are there—for example, with continuity of care—as soon as possible. It is vital that we take families with us and ensure that they are listened to and treated with respect. Let us not waste this real opportunity to change the systems that have been harming families for far too long.
The final key aspect that I would like to address is the need for true accountability. Too often, negligence leads to loss; the failures are there for everyone to see. I ask those who have recently called for a reduction in accountability this: how can accountability be reduced to improve maternity services when it is not even there? I am not talking about hounding midwives and obstetricians, but if someone makes a mistake again and again, as we saw in Nottinghamshire, families have to fight for the truth. Mothers leave hospital having been made to think that they were at fault. There has to be accountability. We need accountability and support to allow midwives to become great. Families should be clear about the process, which should work with them, so that they get answers and the truth without having to fight for them.
Alex Sobel (Leeds Central and Headingley) (Lab/Co-op)
My hon. Friend is making an excellent speech and is a great advocate on this subject. I am sure she knows about the MBRRACE-UK—Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK—data; it shows mortality rates across the country. Like Nottinghamshire, Leeds has high mortality rates—in fact, they are the highest in the UK and 70% higher than the average. Those preventable baby losses are not an accident or a statistical mistake. Does she agree that the leadership of hospital trusts with such high rates need to take accountability and fix them? This is not an issue for individual maternity units; this should be taken on by the chief executive and those at the highest level in teaching hospitals.
Michelle Welsh
I absolutely agree; if we had that approach in Nottinghamshire, the story would have been very different.
This starts with us building a culture that allows people to say, “This went wrong, and this is why. I made a mistake, and I am sorry. It’s time to fix it.” We cannot accept any more maternity scandals in this country. Of course, there will be times when nothing more can be done, through nobody’s fault, but in instances where mistakes were made, clinicians need to come forward. How do we learn from mistakes if they are never identified?
Regulators such as the Care Quality Commission, the Nursing and Midwifery Council and the General Medical Council need to step up. The evidence is there for all to see in Nottinghamshire: the NMC failed, the GMC failed and the CQC failed. All those organisations were informed over and over again about what was happening in Nottingham, and nothing was done—not one thing. To this day, no one has been held accountable.
I welcome the Government’s decision to publish a consultation on secondary legislation in order to modernise regulatory frameworks. I would be grateful to hear more about that. I ask the Government to involve bereaved and harmed families in the process, because regulation must work for families, and to work with organisations such as the Royal College of Midwives to ensure that clinicians are involved. In any reform and change, there must be balance.
It is time for this Labour Government to take action. What successive Governments have allowed to unfold in maternity care tells a devastating story about how little the lives and experience of women are valued. Those of us who were made to feel completely expendable at the most vulnerable moment in our life will know that to be only too true. In choosing how to respond, this Government have a powerful opportunity to send a decisive message about how they view and value women.
It is possible to make change. Every day, I meet fantastic organisations run by people who have used their experience to fuel their work to change lives. They include Jo Cruse from Delivering Better, Sharon Luca from the Luca Foundation, Heidi Eldridge from the MAMA Academy, Laura Corcoran from Dignity Care Network, and Clo and Tinuke from Five X More. I could name so many more.
It is truly astonishing how many people across the country, from all corners of our society, from mothers to midwives, are working themselves to the bone to improve our maternity and bereavement services. They are all pushing for change for women and the babies of the future. This is no longer just a campaign; it is a movement, and if the Government and the NHS do not act now, they risk being left behind. We face many crises in our maternity services, and the only way through them is together. Families, midwifes, mothers, fathers, nurses, obstetricians, charities, decision makers and Members of Parliament must come together in this movement to fundamentally reshape our services, so that safe birth, continuity of care and accountability are at their centre.
All of us here are bound by a shared, heartbreaking truth: no parent should have to say goodbye before hello. Affected families deserve more than condolences. It is up to us in this Chamber to demand an end to the preventable failures, systemic neglect and outdated protocols that steal futures. Grief must become the engine of change. It is not enough to patch a broken system; we must rebuild it, stronger and safer than ever before, for every baby whose life was too short, for every family left shattered, and for every future family depending on us right now. Our task is clear. The time for analysis is over. The time for delay is over. I will not rest until our maternity services are fixed, permanently and profoundly.
We are fighting for a future in which safety is guaranteed, every mother is heard and every birth is met with the excellence and dedication it deserves. Let the memory of the children we hold in our hearts be the light that guides our resolve: baby Harriett, baby Teddy, baby Junior, Amaya, baby Winter, Maya, Dexter, Smokey, baby Ladybird and baby Coupa, the wonderful, kind and funny Ryan, and every baby and mother impacted and gone too soon. We must pledge to them and to ourselves that we will fix maternity services. We will build a legacy of safety so powerful that their short lives will forever protect the long lives of others, and we will do it for good.
Tessa Munt (Wells and Mendip Hills) (LD)
This Baby Loss Awareness Week, we honour those children who are loved and missed, and we recognise the parents, siblings, families and friends who carry their memories every day. Today, I want to emphasise just how vital it is that we see the quality of bereavement care standardised, and that this standard is mandated for every NHS trust and health board.
My constituents John and Holly Osman live in Wells with their two lively children, six-year-old twins named Alex and Amelia. It may surprise some of my constituents that I speak about John, as we do not share a political perspective. However, we share a life experience with each other, many of my constituents and, I understand, one in every two people in this country: the terrible loss of a pregnancy or the death of a baby. That experience transcends all political differences.
Some eight years ago, John and Holly lost their much loved twins, Logan and Lottie, five months into their pregnancy. Logan and Lottie’s lives were short. Logan was with them for 15 minutes and Lottie for 57 minutes. Holly, who is in the Gallery this evening, tells me that registering their births and deaths will remain one of the hardest things they have ever had to do.
John and Holly were lucky to receive excellent bereavement care from the team at the Royal United hospital at Bath, which in 2017 and 2018 was piloting the national bereavement care pathway. Being able to deliver in the forget me not suite, where they receive care from trained bereavement midwives and spent two days with their babies making memories, is something they say they probably did not realise how much they needed then, but that they cherish deeply now.
As Holly highlights, the power of compassionate, skilled bereavement care cannot be overstated. It helps parents begin to process trauma, to create memories and to honour a life, however short. That care does not erase loss, but it brings dignity, acknowledgement and a foundation for healing. The care that parents receive in those heartbreaking moments stays with them forever. No one can turn back the clock, but we can make a difference through having compassion, understanding and better care.
It shocked me that 50% of bereaved parents reported that they were able to access the support they needed, but only 17% were able to do so through the NHS. I pay tribute to the NHS clinicians, midwives and support staff who deliver that care with tenderness and professionalism. Good care helps parents and families begin to navigate the painful journey of bereavement. Whether those NHS staff who engage with the bereaved family during this journey have received specialist bereavement training depends on where that care is being provided.
Poor care can deepen trauma. We know that bereavement leaves parents vulnerable to increased risk of developing mental health conditions. That is why it is essential that every bereaved parent in the UK has access to standardised high-quality bereavement support, including clear signposting, timely referrals and specialist mental health care when it is needed most.
Excellent bereavement care should not be a matter of luck or postcode. The national bereavement care pathway has finally been adopted voluntarily by every hospital offering maternity care in England, with the last trust having adopted it last year. However, in Scotland, the pathway has been mandated by Government. The difficulty with voluntary adoption is exactly that: it is voluntary, which means that the nine standards of care that comprise the bereavement care pathway are not national standards in England until they are mandated by the Department of Health and Social Care. I ask the Secretary of State to consider mandating the bereavement care pathway with immediate effect, so that families and friends can be reassured that care in the most difficult of circumstances will be exemplary.
To Lottie and Logan’s family and to the many others who have written to me, thank you for your courage in sharing the most personal of stories. Your love for your children and your determination to help other families is a gift to us all. We cannot take away the pain of loss, but we can ensure that no parent walks through it alone.
Fleur Anderson (Putney) (Lab)
I welcome this important debate, and I thank my hon. Friends the Members for Sherwood Forest (Michelle Welsh) and for Rossendale and Darwen (Andy MacNae), and the right hon. Member for Godalming and Ash (Sir Jeremy Hunt), for bringing to the House, during Baby Loss Awareness Week, this debate on a grief that touches thousands, who often grieve in silence.
I will use this debate to call for a UK-wide perinatal death reduction programme, and will talk about foetal growth restriction monitoring. I am really glad that the Secretary of State for Health is in the Chamber; that shows his commitment. This debate is well timed to inform the rapid review of maternity and neonatal safety in England.
For many, baby loss is invisible and misunderstood. This week breaks that silence, honours lives cut short and stands with families who carry their babies’ memory every day. Like other Members, I pay tribute to charities like Sands, Tommy’s and the Miscarriage Association. Their work must be supported and recognised.
I speak with a heavy heart to share the story of Maia Devlin Corfield, a beautiful baby girl who should be here today. Her parents Sherena and Jack came to my advice surgery to tell me about Maia’s stillbirth at Kingston hospital. Though Sherena’s pregnancy was low risk, Maia showed signs of growth restriction. Staff reassured Sherena but failed to act. Maia was born still on 29 November 2024. The autopsy showed she was healthy, but died due to a placental condition that halted her growth and breathing.
Babies with growth issues like Maia are eight times more likely to die, and it was Kingston’s foetal growth monitoring system that failed her. It diverged from national standards and, despite early warnings, many unsafe practices like that remain. The Government’s own maternity and neonatal safety investigation into Maia’s death made nine recommendations, yet risks still persist and are not listened to. Sherena and Jack often feel that they are not being listened to, but bereaved parents need to be heard because by listening to them, we can identify those areas that need to change. It is that culture and the regulation and standards that all need to work together to see real change.
Freedom of information requests by Sherena and Jack have revealed that at least 27 trusts cannot properly identify babies with growth issues. The issue is that many hospitals use a global growth monitoring system that under-detects small babies in high-income countries like the UK because it uses data from across the world. Safer UK-developed systems based on NHS data do exist and are used by many units, but Maia was failed by outdated growth charts still in use at Kingston and St George’s and at many other hospitals. A key part of the system is those growth charts. Donald Peebles, NHS England’s clinical director for maternity, has confirmed that a national safety alert will soon advise trusts to stop using these intergrowth charts, but is there a system to track which hospitals still use them, and how can we update foetal growth monitoring systems urgently?
I have also talked to the chief nurse for the South West London integrated care board, who highlighted issues of midwife retention and recruitment and, in particular, maternity triage, which needs reform with a universal standard that would ensure consistency of safety and access—those early warning systems that failed Maia and are failing others. Just as we have a mental health investment standard, we should consider a similar maternity services standard as well.
I turn to the demands for change. The “Saving Babies’ Lives Care Bundle” published by NHS England in June 2023 outlines three key elements for foetal growth monitoring, but they are not consistently adopted and then monitored to ensure that they are implemented. There are too few of those deaths in each trust to rely on the trust to take the action; it has to be done at a national level. In fact, it has to be done across every nation—Northern Ireland, Scotland, Wales and England—otherwise there will be inconsistencies as there already are between the different nations. Will the Minister work with counterparts across the UK to ensure that no nation falls behind? Will the Minister meet Sherena and Jack to discuss how to improve maternity care and look at the findings they have? We owe it to Maia. We owe it to every family shattered by preventable baby loss to demand accountability, enforce standards and ensure that no parent is ever told that everything is fine when it is not.
Edward Argar (Melton and Syston) (Con)
I pay tribute to the hon. Members for Sherwood Forest (Michelle Welsh) and for Rossendale and Darwen (Andy MacNae) and to my right hon. Friend the Member for Godalming and Ash (Sir Jeremy Hunt) both for bringing this debate during Baby Loss Awareness Week and the incredibly thoughtful and moving contributions they have already made to the House. I suspect we will see this House at its best this evening, debating in a measured but passionate way something of huge importance to so many of our constituents.
I welcome to the Public Gallery those family members who have stayed until this late hour because this matters so much to them. I pay tribute to Bliss, Sands and other charities that do so much in this space. It has been a privilege for me to meet, and read correspondence from, constituents of mine who have been affected by baby loss. I have to say, they have carried themselves with the most incredible dignity given what they have been through. I am very conscious that it is something that they will never get over.
I will not use surnames as I have not sought permission, but some families have given me the name of the baby they lost, and I want to place those names on the record, because it matters: baby Wynter, baby Harry and baby Ciara-Mae. I know that they will always be their parents’ baby. It is important that we remember that. I hope to do them justice.
The hon. Member for Sherwood Forest spoke with incredible eloquence when she said that it is about not just mourning the past but fighting for the future. She sums up what this debate must be about if it is about anything. We have seen progress, but it is sadly not enough. As my right hon. Friend the Member for Godalming and Ash mentioned, that progress has apparently plateaued since the pandemic. We still see terrible inequality of outcomes across different groups in our society.
Sadly, giving birth is not risk-free, but by no means are all those baby losses inevitable—many are avoidable. We need to ensure that we do all we can to reduce that risk. When something goes wrong, as sadly it has on too many occasions, families deserve transparency, openness and a fight for improvement. They need to be believed and listened to. We have seen problems in Morecambe Bay, Telford, East Kent, Nottingham—I could go on. Let me focus briefly on Nottingham—as a Leicestershire MP, many of my constituents will have been affected. Donna Ockenden’s work is very welcome; she has built extraordinary trust with the families and those who have been failed. I also welcome the national review that the Secretary of State has put in place, and the work being done by the noble Baroness Amos. I know that the Secretary of State knows this, but I gently say to him that there are different views among the families, and I encourage him and the review team to continue taking the families with them, to work with them at each stage, and to listen to them.
Improvements are needed. My right hon. Friend the Member for Godalming and Ash mentioned the CQC and he was absolutely right to do so. We need to see continued transparent engagement by that review with the families. We need to see whether more can be done to consider the role of the independent regulators. It is important that we look at the support available for both parents when the worst happens and they are bereaved. We need to raise more awareness. I know that the Secretary of State knows that. The families I have spoken to speak well of him. I know him well; he is a decent man and cares deeply about this. I know that he is listening. The fact that a Secretary of State is on the Treasury Bench at this hour and will conclude the debate at around midnight is testament to his commitment—I wish him well in his work.
It behoves us all to continue to strive and do more to reduce the number of avoidable baby deaths and the pain the avoidable baby loss causes. Equally—I echo the words of my right hon. Friend the Member for Godalming and Ash—we must also focus on hope and progress, and on safety, accountability and what more we can do to ensure that a child coming into this world is not a moment of sadness and grief but a moment of joy. I wish the Secretary of State well in his work on that.
Naz Shah (Bradford West) (Lab)
I thank my hon. Friend the Member for Rossendale and Darwen (Andy MacNae) for his work to secure this debate and for sharing his personal experience. I also thank my hon. Friend the Member for Sherwood Forest (Michelle Welsh). Hearing people’s personal experiences makes this a better place for us to legislate and do what we have to do, so I thank my hon. Friends very much for sharing, which takes bravery and courage. I am sure that the whole House shares those feelings.
Losing a child is one of the most devastating experiences that any parent can face, as other Members have said. Words cannot describe the immense personal pain of dealing with such grief. To carry a child for nine months—sometimes less—and to dream of their future only to lose them is simply unimaginable.
As a mother of three, my heart goes out to every parent who has endured the heartbreak of losing their child or baby. This debate, during Baby Loss Awareness Week, could not be more timely. Baby loss is not just a personal tragedy but a public health issue, in particular when it occurs as a result of preventable errors or gaps in care that we have the power to fix.
Baby loss has a deep and lasting impact not only on mothers and fathers, but on siblings and entire families. For some, that pain comes immediately after the loss; for others, it may take weeks or months before the full emotional weight is felt. That is why I welcome the amendment to the Employment Rights Bill that will extend bereavement leave to those who experience pregnancy loss. I thank my hon. Friend the Member for Luton North (Sarah Owen), the Chair of the Women and Equalities Committee, for her work in driving that change.
It cannot be right that someone who suffers a miscarriage in the morning, losing the future that they dreamed of, is expected to turn up at work at 9 am as if nothing had happened. I am proud that the Labour Government have recognised the real human cost of such a loss, and ensured that families receive the time, care and support that they need to begin to heal.
In Bradford, we have seen the devastating impact when maternity care falls short. Bradford teaching hospitals NHS foundation trust is one of the 14 NHS trusts now under review for historic maternity failures—a clear sign that systemic change is urgently needed. In November 2021, two newborn babies tragically lost their lives at Bradford royal infirmary after lapses in hygiene allowed a drug-resistant superbug to spread through the neonatal unit. A report found that staff were not consistently following hand hygiene guidelines and were unclear about the use of protective equipment. These were preventable deaths, heartbreaking for the families involved.
I welcome the measures that the trust has since put in place, but we must ensure that lessons are truly learned so that no family ever has to endure such pain again. Every mother deserves to give birth knowing that she and her baby will receive the best possible care—care rooted in safety, dignity and compassion.
In Bradford, a mother gave birth to her son on 13 February 2023; sadly, he passed away the next day. She was moved between units with little communication and no explanation of what was happening. She was not offered a transfer to another trust where her baby might have received neonatal care and a chance of survival. Her son was born alive but died in her arms, and her records were later found to wrongly describe the loss as a miscarriage. No mother should have to endure such failings. In describing what she went through, she said:
“My experience at Bradford Hospital’s maternity unit destroyed me. My son died after birth. I nearly died myself, but they didn’t care. They sent me home the same day he died, even though I had clear signs of infection. I left that hospital with not just empty arms, but with a body that has never been the same. Now all I have is a baby I can visit at the graveyard and a lifetime of pain that they caused.”
In my own constituency, I have consistently advocated the concern about the standards of maternity services and the leadership at the Bradford teaching hospital trust. On new year’s eve last year, a couple from Bradford were wrongly told that their unborn baby had died; the day after, she was delivered fit and healthy. Jamal and his wife Fozia were told by doctors that there was no heartbeat when they went for a routine test. They described their experience as going through hell and back. No parent should ever have to experience such pain and uncertainty. I have written to the Secretary of State, and I am glad that he is taking notice.
I welcome the maternity review being led by Baroness Amos, but lessons must be learned. The failures at Bradford really need to stop, so that nobody goes through such experiences again.
Mr Tom Morrison (Cheadle) (LD)
Genevieve Meehan, affectionately known as Gigi, was born on 18 July 2021 at Stepping Hill hospital. She was small but perfectly formed, and by all accounts the happiest little person anyone could meet. Gigi loved dancing with her big sister, trying spaghetti bolognese and playing with her favourite green tambourine. Those are the precious, ordinary moments that make up a childhood—the moments that every parent treasures and that we photograph, remember and hold dear. Gigi had been reaching the magical milestones that fill parents with pride and wonder: she waved for the first time, she pulled herself up to stand and she said “Da-da”. Each of those was a cause for celebration and a promise of all the milestones yet to come.
Gigi’s parents, Katie and John, did everything right. They chose a nursery that was well known in the area, had positive recommendations from friends and had respectable Ofsted results. They visited multiple times and attended settling-in sessions. The staff seemed well trained and capable. It felt safe. They trusted that nursery with the most precious thing in their lives, but in May 2022, that trust was shattered. Gigi, a loving and happy 10-month-old girl, was left strapped to a bean bag, face down, without being checked by the nursery staff. She died at nursery. The nursery was not safe, it was not caring and it failed Gigi at the cost of her life.
No parent should ever have to experience what Katie and John have experienced. No parent should have to bury their child because basic standards of care were not followed, or to campaign for changes that should already exist in order to protect the children who come after, yet that is exactly what Katie and John are doing. In the face of the most earth-shattering loss imaginable, they are campaigning tirelessly for Gigi and to make our nurseries safer for all children.
As a new father, I cannot begin to comprehend the devastation that Katie and John have endured. When I look at my daughter, Poppy, I see the same joy, wonder and infinite promise that Gigi brought to this world, and I am haunted by the knowledge that what happened to their daughter could happen to our children. Katie and John are not alone in their grief: it is an all-too-common story that nationally agreed standards of care are not being adhered to, leading to avoidable deaths, whether in maternity units, neonatal care, nurseries or crèches.
Gigi’s campaign has already achieved important progress. Ofsted inspections will be more frequent—every four years instead of every six years. In collaboration with the Lullaby Trust, the early years foundation stage statutory framework will be updated to include more detailed safe sleep guidance, but that cannot be the end. Mandatory safe sleep training for all staff is needed, CCTV should be implemented in all nurseries and far more Ofsted inspections must be unannounced. There can be no doubt that the lives of babies and their families will be saved if those measures are seriously considered and implemented by the Government.
As the Sands and Tommy’s policy unit report, “Saving Babies’ Lives 2024”, states:
“With political will, progress is possible.”
This Government must have a relentless political will in ensuring that our nurseries and maternity units are the very safest of places. No babies should ever lose their lives at the hands of inadequate standards of care, a reliance on whistleblowing culture or a lax inspection routine.
Katie and John should be watching Gigi grow up. They should be seeing her starting school, making friends and discovering who she is. Instead, they are fighting to ensure that no other parent endures their nightmare. We owe it to Gigi, we owe it to Katie and John, and we owe it to every parent who trusts us to keep their children safe. We have to do better.
Juliet Campbell (Broxtowe) (Lab)
I thank my hon. Friends the Members for Sherwood Forest (Michelle Welsh) and for Rossendale and Darwen (Andy MacNae) for securing the debate. It coincides with Baby Loss Awareness Week, a time when we pause to remember every baby who has been lost far too soon. The week provides us with a chance to take stock of this sensitive issue and to commit to supporting family members, including fathers and siblings, by improving services for all families affected by baby loss.
In 2023, there were more than 4,000 baby deaths in the UK, behind each of which is a family whose lives will never be the same again. The pain that those families experience is the same as the pain of losing any child, and they deserve to be treated with the same sensitivity as with any other bereavement. Although we have made significant progress over the past few decades, the rate of baby deaths remains too high, and disproportionately so in African, Caribbean and Asian families and those from deprived backgrounds. That inequality is a challenge that our society, our NHS and our Government must address urgently. Our NHS maternity and neonatal services must have proper funding and training to provide care and support through a service provision that recognises the medical, social and emotional needs of those families. It also means ensuring that staff have the support to offer a service with empathy and compassion, and to understand that baby loss has a profound impact on all members of the family. Every parent experiencing miscarriage, stillbirth or neonatal loss deserves a safe space where they can grieve with dignity.
Finally, I take this opportunity to pay tribute to Forever Stars, a charity based in my Broxtowe constituency founded by Michelle and Richard Daniels, who have lived experience of baby loss. Their strength and dedication to families who have experienced baby loss has flourished into an organisation that provides understanding and comfort to hundreds of families across Nottingham and Nottinghamshire, but that should not have been left to a grieving family. The creation of baby loss services, memorial gardens and specialist bereavement spaces should be a standard part of our health and social care service. I therefore call upon the Government to see this as an opportunity to design and develop improved services for families who experience baby loss.
Sarah Gibson (Chippenham) (LD)
My constituent’s sister was stillborn many years ago, in a situation in which my constituent’s mother was simply told, “Don’t worry, dear, you’ll have another one next year.” There was no bereavement counselling and, more importantly, no marked grave. My constituent found out some years later—quite recently—that his sister had been buried in a communal unmarked grave. It appears that, because this practice went on until the late 1980s, there are some 89,000 such children. These families have had the lifelong pain of not knowing where to grieve, how to grieve or where to focus their attention, with no chance of finding it.
These children deserve our support, and I hope that this House will share my view that the Government need to step in to provide a small memorial so that these families can have a focus for their grief, and some acknowledgment that these children existed. I would be grateful if the House shared this call, which I have tabled as an early-day motion. I know the Minister has kindly offered to meet these families, and I am extremely grateful for his support.
Mrs Sharon Hodgson (Washington and Gateshead South) (Lab)
I am very glad to be able to take part in this very moving debate and to follow so many excellent speeches as we once again mark Baby Loss Awareness Week, not least on behalf of myself and my story, and that of my beautiful baby Lucy, who I tragically lost back in 1998, but also on behalf of all the MPs in this place, women and men, who are not yet ready or able to stand and tell their story, as indeed I was not for so many years.
For almost 20 years I never spoke of my loss, and I never told anyone who did not know me back when it had happened, until I helped to set up the all-party parliamentary group on baby loss back in 2016, 11 years after I was first elected. That was along with a cross-party group of MPs, all of whom are no longer in this House, although Baroness Prentis of Banbury is now in the other place. I told them my story in the Tea Room, and I could point to the table that we sat around to share our stories through floods of tears. It was the first time I had spoken about it in any detail since it had happened two decades earlier. Baby loss was, and I think it may still be to a certain extent, the last great taboo that a lot of parents have to navigate their way through.
Not long thereafter, I was approached by one of the officers of the new all-party group regarding the private Member’s Bill introduced by the former Member for East Worthing and Shoreham, Tim Loughton. As those Members who were around at the time will remember, part of that Bill covered baby loss and the lack of any recognition for stillborn babies born before 24 weeks—what are, in law, still called late-term miscarriages. His private Member’s Bill tried to address this through what would become known as baby loss certificates. He had been approached by his constituents Hayley and Frazer, who gave birth to their son Samuel at 19 weeks. Tragically, he was stillborn, and they had been horrified to receive no official recognition and—even worse—to learn that their child was entered in the official records as a miscarriage, as indeed my Lucy was at 23 weeks and four days, just a few days short of the legal definition for recognition.
Tim also cited another tragic case, that of twins born either side of that 24-week threshold. One thankfully survived and was given a birth certificate, but the other—born just a day or so earlier on the wrong side of 24 weeks—tragically did not survive, received no official recognition, and was entered in the official records as a miscarriage. This felt grossly wrong to all those parents and to Tim, as it did to me and my husband when it happened to us. Tim set about trying to change the law, hence approaching me to see whether I would be brave enough to stand here—on the Opposition Benches as I was then—and tell my story, as it was so relevant to the case he was trying to make. Somehow, I managed to do it—it is all down on record for anyone to read or watch, so I will not repeat it today—and it involved an awful lot of tears. Those who have spoken today have somehow managed not to be in floods of tears. I did it, as lots of Members have done today, and I commend them all for sharing their heartbreaking stories. We should remember, though, that for every Member who bears witness in this Chamber, there are no doubt many more who are not yet ready to do so.
I was very proud of myself back in February 2018 to give mine and Lucy’s story in detail in that private Member’s Bill debate, and for my experience and Lucy’s all-too-brief life to perhaps have made a difference in helping to change the law and bring about the baby loss certificates, which are now much treasured by so many parents. It is something I am still very proud of.
After that debate and all the publicity it garnered, the right hon. Member for Godalming and Ash (Sir Jeremy Hunt)—who was Health Secretary at the time, and who I pay tribute to for everything he did—set up an official Department of Health expert working group, which Tim and I sat on, to consult on what a change in the law would look like and how the baby loss certificates would work. I was very glad when in February 2024, just before the election, the last Government announced the roll-out of the first ever baby loss certificates.
As welcome as those certificates are, I worry that there are still some unintended consequences, as there often are when first enacting new policies. I have been contacted by Catherine, whose much-wanted baby died at 12 weeks. Through the grieving process, she found comfort in knowing that she would get a baby loss certificate for her son Matthew. However, when she applied for that certificate, she found that she was not able to add her partner’s name to it, as he was registered with a GP on the Scottish side of the border. While relationships across the English-Scottish border are not common, neither are they unheard of. Catherine asked me to ask the Secretary of State—I am very happy that he is in the Chamber in person tonight—what steps could be taken to enable both parents’ names to be included on baby loss certificates where those parents are registered with GPs in different countries in the UK. I am sure that what I have described is an anomaly, and I hope the Secretary of State will address it in his response.
Due to time, I will leave my remarks there, Madam Deputy Speaker. I thank you for your grace.
Madam Deputy Speaker (Caroline Nokes)
I appreciate the hon. Lady finishing her remarks. Members will have noticed that I indulged the hon. Lady, but unfortunately after the next speaker I will have to reduce the time limit to four minutes so that I can get all Members in.
Monica Harding (Esher and Walton) (LD)
I thank the hon. and right hon. Members for bringing this debate to the Chamber today. I thank other speakers for their moving remarks, and it is a privilege to follow the hon. Member for Washington and Gateshead South (Mrs Hodgson). I thank her for sharing her story, on behalf of all those untold stories. I speak for all my families in Esher and Walton who have dealt with baby loss. Their stories are many, their grief is unlimited, and I pay tribute to them and those families with us today who are intent on turning their grief into others’ hope. Your bravery humbles us all.
Today, I will focus on one family. Last week I was visited by my constituents, the wonderful, brave parents of Jimmy Alderman, whose story reminds us that there is still so much we must do to protect our youngest and most vulnerable. Jimmy was just six weeks old when he died last October. He had been breastfed while being carried in a sling at home, which many parents understandably see as practical, safe and nurturing. Tragically, Jimmy slipped into an unsafe position and lost consciousness. Despite his parents’ desperate attempts to save him, he died three days later.
Following the inquest, the senior coroner issued a prevention of future deaths report, which found that guidance available to parents on the safe use of baby carriers and slings, particularly when feeding, was wholly inadequate. The coroner highlighted the absence of clear NHS advice, the lack of visual guidance showing safe versus unsafe positions and the limited awareness of suffocation risks, especially for newborns and premature babies.
In response, the National Childbirth Trust and the Lullaby Trust have both updated their advice, warning that hands-free breastfeeding or bottle-feeding when using a sling is unsafe, particularly for babies under four months old. Their message is now clear that if a baby needs to feed, they need to be taken out of a sling. Those are important steps, but it should not fall solely to grieving parents and charities to close such critical gaps in public information. National guidance must keep pace with modern parenting practices, and it is vital that the NHS clearly sets out the risks and best practices around baby carriers and feeding safety.
Jimmy’s parents have shown extraordinary courage, and in Jimmy’s memory they are calling for a couple of simple, but vital reforms. First, they want a national awareness campaign to promote the safe use of slings and carriers. Secondly, they want consideration of tighter regulation in industry standards for baby carrier safety. Those sensible, achievable measures could save many lives. That is what Jimmy’s parents are motivated by. Nobody should have to go through entirely preventable grief, as they have.
Will the Minister agree to meet with Jimmy’s parents and me to discuss how the Department of Health and Social Care can support this campaign, including through updated NHS guidance, a national awareness initiative and a review of safety standards for baby carriers? By working together, we can ensure that Jimmy’s short life leads to lasting change and that no other parent has to endure the unimaginable pain that his family has faced.
Jess Asato (Lowestoft) (Lab)
I thank the hon. and right hon. Members for securing today’s debate on such an important issue that is sadly too often overlooked. Earlier this year, I was incredibly grateful to meet Angels and Rainbows, a local group in my Lowestoft constituency run by bereaved parents who support others through the experience of baby loss. I put on record in this place my sincere thanks for their vital work, which is life-affirming, trauma-informed and grounded in the realities of grief. One key issue they wished me to raise today was how women who have just lost a baby are placed on the same wards as those who have just given birth.
It feels deeply cruel that parents who have just been through the trauma of child loss should have to share the same space as joyful new mothers and healthy new babies making their first cries. That is why hospitals should provide a space away from new parents and the maternity unit, so that parents can grieve in peace. As my local hospital, the James Paget, is brilliantly part of the new hospital building programme, I hope that its senior leadership looks at the need for a dedicated private space for bereavement care in its plans.
Training is key, too. Parents told me how vital it is for staff to receive appropriate training in how to communicate sensitively with families going through baby loss. As one constituent said:
“I felt the staff weren’t prepared or prepared me on what was happening or going to happen. It was as if it was a taboo subject.”
The quality of care received by my constituents has been very inconsistent, with some feeling well supported and others not at all, particularly once they were out of hospital. One of my constituents found out at her 12-week scan that she had suffered a “missed miscarriage”, and was given medication and told to expect an experience similar to a bad period. Instead, she nearly passed out from the agonising pain, had contractions, and passed the pregnancy on her bathroom floor at home. She had been given no guidance on what to do next, and was not given any reassurance when she reached out for advice. She was not offered a follow-up scan, contacted by a midwife, or signposted to counselling or a specialist service. Left without support, she was later diagnosed with PTSD.
Unprepared staff, the dearth of support services and long waiting times for counselling make this horrible situation worse, and it is important to recognise that fathers too are suffering from that lack of support. Dads have told me that they even felt ignored by services, while also needing to support their partners in turn. We must do better, for everyone, which is why Angels and Rainbows is campaigning for a full-time bereavement midwife or bereavement support worker in every hospital. For a while we had one at the James Paget, and some really positive changes had been made as a result and through work with our intrepid support group. Sadly, in May this year that role was cut, despite the trust’s acknowledgment that the role was “undoubtedly beneficial to families”. While all midwives need training, it takes a lead to help to co-produce change with those with lived experience, drive it through and then, importantly, sustain that change.
In the words of one of my constituents, baby loss
“is not ‘just’ a medical event. It is the loss of a child, a dream, and a future. Without compassionate systems in place, the trauma of miscarriage can last a lifetime.”
With her words to close my speech, I am grateful for the opportunity to participate in this moving debate during Baby Loss Awareness Week.
Chris Coghlan (Dorking and Horley) (LD)
I commend the hon. Members for Sherwood Forest (Michelle Welsh) and for Rossendale and Darwen (Andy MacNae) and the right hon. Member for Godalming and Ash (Sir Jeremy Hunt) for calling this important debate. I have seen at first hand the commitment of the right hon. Member for Godalming and Ash to these issues, and I applaud his dedication.
On Thursday I sat down with my constituents Jamie and Ellie Thompson. They lost their son Billy on Easter Sunday 2024, just 15 days short of his fifth birthday. It was diffuse intrinsic pontine glioma, one of the rarest cancers and one of the worst. It attacks only children, it attacks the brain, and it is untreatable. Billy was the brightest, most cheerful little boy. He loved superheroes and he loved rugby, just like his dad. His mum said that everyone who met him fell in love. One day he was playing at the beach with his sister Maddie and his parents, and he was not his usual self. Five months later, he was gone.
Jamie and Ellie told me how their beautiful boy became angry, anxious and in agony. They spoke of their terrible struggle to look happy in front of him, before breaking down in the room next door. One day Billy said, “Mummy, I can’t see,” as he slowly lost his eyesight and the use of his limbs. Sadly, mistakes in palliative care meant that his last days were brutal too. Today, his family are trying to make sense of it all. Jamie took out his anger on playing a season of hard rugby; Ellie threw herself into her local community projects in Billy’s memory. They both suffer from flashbacks, but thankfully Maddie is now eight and seems to be OK.
Time and again, I have seen people take tragedy in their own lives to turn it to positive change for others. Jamie and Ellie have started a charity, Billy’s Battalion. They are fundraising to support five promising trials of DIPG treatment at Great Ormond Street hospital, and I ask the Secretary of State to see whether there is anything that the Government can do to support it. This is what Jamie and Ellie are doing to honour Billy’s memory, and it is people like them who inspire me the most.
Olivia Blake (Sheffield Hallam) (Lab)
It is a privilege to speak in the debate, and I thank the co-sponsors and the Backbench Business Committee for allowing it to happen on the Floor of the House today. I also thank everyone who has spoken so far and so bravely, whether that is sharing their own experience or that of their constituents. These debates have a true impact.
This issue is of profound personal significance to me, as it is to so many families up and down the country. Alongside Tommy’s, many Members of this House, Myleene Klass MBE, Sands and the Miscarriage Association, I have been campaigning for five years for simple changes. First, I want to recognise those for whom this is not an abstract discussion but a reflection of one of the hardest chapters of their lives. To every parent who has experienced the heartbreak of losing a baby, I want to say, “Your loss matters, and your voice matters.”
Time and again, investigations into maternity and neonatal care have revealed the same issues: poor communication, missed warning signs and families left to fight for answers. National standards of care are not being followed, and too often bereaved parents are left wondering whether lessons will ever truly be learned. That is why the forthcoming national investigation into maternity and neonatal services is so important. It must drive lasting change, and I urge the Secretary of State, who I am so pleased to see in his place, to ensure that there is clear national oversight of how any recommendations are implemented. The investigation must also take ambitious approaches to improving maternal heath and reducing baby loss.
We need a focused national strategy that sets new maternity safety ambitions, tackles inequalities and ensures consistency across all services, and I want to briefly mention infertility services. I have decided that locally commissioned services are simply not good enough—they are not fit for purpose. In some places, you get nothing; in other places, you get three cycles of in vitro fertilisation, as NICE suggests. In other places, you have to pay thousands of pounds if you are LGBT. As shown by “Joy”, the Netflix story that was told so well, the same backward thoughts about infertility treatment still exist in local commissioning boards.
That is no more so than in South Yorkshire, where the NHS trust is currently consulting on—I am quoting from the website—views on
“how many cycles of IVF should be provided to people in South Yorkshire”
and on
“how much gluten-free…produce should be prescribed”.
I have coeliacs in my family and understand the struggle, but to compare that to the loss of babies, which many couples who go through IVF will have suffered, is simply not good enough. The trust’s own numbers show that the saving from reducing two cycles to one would be only £280,000 a year. That would be less than 2p per person in the whole ICB area. Let us take that money centrally, so that no matter where you live in the UK, you have access to three chances to start a family. You might have suffered five miscarriages, three miscarriages, baby loss or stillbirth. You might be being told by your doctor not to try for a baby given the risk to your life, and only to get support through IVF.
It is simply not good enough, and fertility services are also diagnostic. I know people who have had endometriosis, polycystic ovary syndrome, blocked tubes, endometrial cancers, polyps or fibroids discovered not through going to a gynaecologist, but through going to a fertility doctor. We should value that and not just see it as an excess cost. I think fertility services should be taken back centrally and provided on that basis.
John Milne (Horsham) (LD)
I pay tribute to all the moving speeches we have heard so far tonight.
There are few losses in life more devastating than that of a child—it is every parent’s greatest fear—but when a baby dies just as life is beginning, at the very moment when joy and expectation are at their highest, the pain is all the harder to bear. Chloe and Toby from my constituency of Horsham, along with nine other Sussex families, have gone through this unimaginable experience. Their babies died in the care of the University Hospitals Sussex NHS trust between 2021 and 2023. Chloe and Toby are not natural campaigners; it is not something they ever expected or wanted to do. They are simply grieving parents looking for truth, accountability and, above all, change.
University Hospitals Sussex, like public services in general, is under immense pressure. Staff are working in a system stretched beyond capacity. I want to acknowledge the efforts of the countless clinicians, midwives and support staff who show up day in, day out. They, too, have been let down by the system; it is not just the families. Nevertheless, the fact remains that something has gone seriously wrong. Nine babies have died in circumstances that the families believe were avoidable, and thus far they have not had satisfactory answers.
Fundamentally, this is about trust. Trust needs to be restored. For that to happen, we first need to fully understand what went wrong. I understand that things can go wrong in any profession—and my own father was an obstetrician—but, unfortunately, in obstetrics the consequences can be devastating. I very much support the words of the right hon. Member for Godalming and Ash (Sir Jeremy Hunt), who said that this is not about launching some kind of witch hunt, which could actually get in the way of preventing further tragedies in the future, because the key thing, and what we need to focus on, is avoiding blame and openly sharing and fixing problems. However, we must shine a light on past mistakes.
In Sussex, Members of Parliament from across the House are working together on this issue, and I look forward to continuing those conversations with my colleagues locally later this week. However, the trust itself acknowledges that improvements are needed, and I welcome the work already under way to make maternity care safer. However, if this review is to succeed and to carry the confidence of the very people it is meant to serve, it must be guided by the right person. The Government have appointed Baroness Amos to lead the review. She commands great respect, and I have no question about her personal abilities or integrity. However, as I have said, the key issue here is trust, and in that respect she is not the right choice for Sussex. I ask the Secretary of State for Health to listen to what the families are saying in Sussex, which is that Donna Ockenden be appointed to oversee the review at University Hospitals Sussex.
Jess Brown-Fuller (Chichester) (LD)
I thank my hon. Friend for highlighting the trust that Donna Ockenden has built through the work she has done, with those Sussex families, and indeed families in Nottingham, Shrewsbury and Telford. Her report in 2022 laid out immediate and essential actions. She deliberately did not call them recommendations; they were actions that needed to be taken. They must be delivered in full, so does my hon. Friend agree with me that we cannot lose any more time and that those actions need to happen alongside the inquiry that is now taking place? We cannot afford to delay, and these families deserve to see those actions implemented now.
John Milne
I thank my hon. Friend and fellow Sussex MP for her intervention, and I very much agree with her. Donna is a midwife herself, and she has been personally involved with the families in Sussex.
Richard Burgon (Leeds East) (Lab)
The points that the hon. Member is making about the choice of people to oversee the review or inquiry reflect the points made to me by two of my constituents, Amarjit and Mandip, who would have their daughter with them today were it not for failures at the Leeds general infirmary. The point they made to me is that they want any review or inquiry to be clearly and demonstrably independent from the people who had a role in running the Leeds teaching hospitals NHS trust in the past. Does he agree with me and my constituents on this point, and does he share my hope and trust that the Secretary of State will weigh that request very heavily before he meets the families?
John Milne
I thank the hon. Member for his intervention, and yes, that sounds like a very similar situation. As I have said, this is all about trust.
I understand that concerns have been raised about Donna’s workload and the risk of relying too heavily on one person, but Donna has indicated that she is willing to participate. I am sure that she would not say so unless she were confident that she could give this task the care and attention it needs. Unless we restore trust, we risk further harm, further delays and further grief, which none of us wishes to see.
Lee Barron (Corby and East Northamptonshire) (Lab)
Almost 15 years ago, my constituent Lauren Trevillyan lost her son Olly. She told me how the support just was not there—not for the families, not for the parents, not for the children. There is just not enough aftercare for people after such a loss, not physically and not mentally. To this day, Lauren is still waiting for a response to her request for counselling. Lauren struggled through those dark months, but now she is fighting for others. Lauren has been the driving force behind the baby loss awareness drop-in at Corby library over the past week, which is absolutely something we should all be behind. We need to talk about this openly and honestly. We have to break the taboo, because sadly it is far more common than people think. As has already been said, in this country 13 babies a day die close to birth.
When I talk about baby loss, I cannot do so without raising the courage and determination of numerous families in Corby who continue to campaign and fight for answers: answers on rare childhood cancers, on multiple miscarriages and on those born with limb deficiencies. Toxic waste was dumped in Corby and we need answers. These families have questions that the local authority is not prepared to answer. In a response to the families’ solicitor, the council said, when it was asked where the toxic waste was dumped:
“The Council understands its obligation of transparency…but considers the weight of public interest…falls in favour of non-disclosure.”
Families are concerned that those with rare childhood cancers or multiple miscarriages are in certain places in Corby where whistleblowers have come forward to say that toxic waste was dumped. It is not good enough. Families are entitled to answers. If the local authority continues to refuse to be transparent and honest, and to answer the families’ questions, then I will lead their calls for a public inquiry. We have to end the defensiveness of our public bodies, either through their own integrity—as it should be—or by the Hillsborough law or, if needed, by public inquiry. Enough of the defensiveness. It is time for answers. We are determined to get them and the people of Corby deserve to hear them.
Bobby Dean (Carshalton and Wallington) (LD)
I thank the co-sponsors for securing the debate and for all colleagues’ powerful contributions so far tonight. Many of those contributions have focused on preventable baby loss, calling for lessons to be learnt and for more to be done, which I fully support. However, I would like to take this opportunity to shine a light on the many occasions when baby loss is not preventable, but where I believe there is still more that could be done as a society.
Earlier this year, my wife and I had an early miscarriage. It was our first pregnancy and we were extremely excited when we got the positive test result. We were very quick to tell all our friends and family. We had no negative signs ahead of our 12-week scan, but during that scan it became quickly apparent that something was not right. We were asked whether it was possible that it could have been nine weeks. Then a second staff member came in and shortly after we were told that there was no heartbeat. We were moved to another room where we asked all the questions that I am sure many ask in this situation. Was there anything we could do? Is there anything we could do differently next time? We were reassured that, actually, it was extremely common, there was nothing we could have done, and that it happens to around one in four or five people.
On our journey home, we felt a bit silly for not knowing that fact and for not being prepared for how common that type of miscarriage was. We wondered why we had not been told in our early antenatal appointments that it was a possibility. We also wondered why we had not heard that so much from friends and family, or seen it in conversations on the TV. After that, we pledged that we would talk about it more.
After that moment, we were faced with some morbid choices: a natural miscarriage, the opportunity to take some pills, or some sort of surgical procedure. We were given a leaflet to think about it and off we went. We did not actually have the opportunity to make that choice, because shortly after we found out the miscarriage started to happen naturally. I can only say that I was not prepared for the level of brutality that that would entail. We were told that it might be like period pains, but it was much more severe than that for my wife and the volume of blood was unsettling. I could not believe it was normal while it was happening.
We started googling and looking online for advice, and we were lucky to find blogs by Tommy’s and other organisations that have been mentioned today, which provided us with some reassurance. However, we still ended up going to A&E because we were concerned about the blood loss. They gave us some reassurance, and we managed to go home with some medication and to get through that event. The follow-up from that traumatic incident in our lives was a simple phone call; we had to report a negative pregnancy test a few weeks later, and that was the end of the support.
Before I run out of time, I must add that we were keen to get on, and we have since got pregnant again. We have jumped that 12-week hurdle, and we are now aware that the chances of miscarriage have greatly diminished, so we are in a better place than we were. However, we are still wondering about what more can be done to provide reassurance to people in that really troubling moment.
I ask the Secretary of State whether we can record every miscarriage so that we can get firmer statistics about how often this happens. I ask him also to look at whether we can provide access for people 24 hours a day so that they do not have unsettling moments wondering if they need to attend A&E, and whether the mental health support that is in place after a third miscarriage could be in place from that very first moment, because it is a deeply traumatic event for anybody to go through. I think we need to talk about it as a society much more, so that the next couple is prepared.
Nadia Whittome (Nottingham East) (Lab)
I start by thanking Members for bringing this important debate and thanking those who have spoken so bravely about their own experiences of loss and harm. No matter how a baby dies or a wanted pregnancy ends, it is always deeply painful and traumatic for bereaved families, but their suffering is particularly exacerbated when the loss of a baby could have been prevented. I have constituents who tragically know that only too well.
Our city is at the centre of the largest maternity inquiry in NHS history and a corporate manslaughter investigation due to failings by Nottingham University Hospitals that have led to hundreds of baby deaths and injuries—hundreds of preventable tragedies. Many families are still waiting for answers. Many have faced contemptuous treatment, not just at the time of the loss or injury of their baby, but in the aftermath. These families have been institutionally gaslit, lied to and robbed of so much, and they are still having to fight for their children. Some have also faced abhorrent racism.
I pay tribute to the Nottingham affected families group for their unwavering determination to secure accountability and change. It is because of their tenacity that the review is happening at all. It has been a privilege to work with them, and I have been deeply moved by their strength and selflessness in fighting not only for their own families, but for others, in the face of such appalling institutional failures and systematic neglect. I also thank Donna Ockenden for agreeing to lead the review and for all her work so far—I am so grateful that families in Nottingham have such a champion fighting their corner.
Above all, there must be accountability for this scandal, and lessons must be learned so that no family has to go through such an avoidable tragedy again. While standards of care at NUH under new leadership have improved, they are still falling short, and further action must be taken to ensure that parents and babies receive the care that they deserve.
I welcome the Government’s launch of a national maternity investigation to examine maternity and neonatal services across England. This rapid review will consolidate previous inquiries’ findings and recommendations, with the aim of improving the quality and safety of maternity care. However, I am concerned that families in Nottingham do not feel that they were included in the meaningful way they were promised, and the Government must not simply wait for the outcome of this investigation before taking action. I am certain that the Secretary of State will act on that, and I thank him for his ongoing genuine commitment to this.
The Nottingham affected families group has been calling for the 22 national recommendations from the Shrewsbury and Telford Ockenden review to be implemented without delay. The families also want the role of oversight bodies, which are meant to hold trusts and healthcare professionals to account, to be scrutinised. The CQC must become a more visible organisation and it must be able to bring prosecutions more than three years after the offence occurred; the current limit is far too short, and it is denying people even a semblance of justice.
There is so much more to say, but in the last few seconds I want to pay tribute to charities in Nottingham founded by bereaved parents, particularly Zephyr’s and Forever Stars. These organisations are already doing the work of supporting grieving families, but they are operating on shoestring budgets and generally do not receive statutory funding. We need to see that change. We need to see statutory funding increase and for those allocating it to recognise that these charities are best placed to provide those services, as they have already built relationships of trust within our communities.
Jim Shannon (Strangford) (DUP)
First, I commend all Members who have told their personal stories and shared with us how their life has been touched by what has happened to them, and how they have tried to move on. I think of my mother Mona, who is 94 years of age and has suffered many miscarriages. My speech writer Naomi—obviously a very busy lady—had a miscarriage as well. We all have personal stories of this, whether through our family, extended family or those we live with.
In 2023 in Northern Ireland, there were 67 stillbirths and 80 infant deaths registered, and for those mums and dads, my heart simply aches. I pay tribute to the friends and families, charities such as Sands, and so many others who rally around those going through the unimaginable. The support they provide is phenomenal and life changing, and that must be placed on record.
I also highlight the tremendous decision to help those who are in the early stages of grieving a loss by making available a baby loss certificate. A certificate does not mean less pain by any stretch of the imagination, but it does provide validation; it says that a wee life existed, was here and was real, and that it is okay to grieve for that wee life and the promise and hope for tomorrow that has passed. In Northern Ireland, we do not yet have those certificates, but my hon. Friend the Member for Upper Bann (Carla Lockhart) called for them in the House just last year.
Whether a loss is felt in the fifth week, the 15th week or the magical 25th week, the fact remains that it is a loss. While some are able to put their words into a song or a poem, and others release grief with the planting of a tree that they can watch grow, and that shows them the passage of time, others choose never to speak of it—and all of these are valid. I often think of a very special constituent of mine who came to me some 45 years after she had lost a baby and asked me how to find where the remains had been buried. The hon. Member for Corby and East Northamptonshire (Lee Barron) referred to things happening in his constituency; some of the things that happened in Belfast over those years would also pose many questions.
I wish to recall the story of that lady. She was part of the “don’t talk about it” generation, yet for all those years, she carried that grief, and wanted to know where her baby boy was resting. The baby had been taken from her, and she was not given the option to bury him. While we both believed sincerely that he was safe in the arms of Jesus, she wanted to know where he was on this earth. This is a subject to which the hon. Member for Corby and East Northamptonshire referred. Agnes passed before I could find out which of the unmarked baby graves he was in, but I take great comfort in knowing that she has finally met him in glory now.
I tell the story of Agnes because it shows the lifelong grief that can be felt. I believe that this debate, and the ones like it held every year, are not simply about what must be done; they are a way to tell the Agneses of this world, who grieved in silence, that they are not alone. Each life is so precious, and the loss must be acknowledged and felt. On behalf of the mums and dads of my constituency of Strangford and across the United Kingdom of Great Britain and Northern Ireland, we honour those little lives, and the indelible little footprints left on hearts throughout the United Kingdom. You were here, you mattered, you were loved, and you are not forgotten.
Samantha Niblett (South Derbyshire) (Lab)
I want to thank the three Members who secured this debate. It is of profound importance. Not long after becoming an MP, I was contacted by Hayley Johnson, who wanted to speak with me about her heartbreak. In April 2025, Hayley found out she was pregnant with her daughter Evelyn. Up until she was 26 weeks and six days, she did not once see a GP, and was given only phone call appointments. On Tuesday 5 August 2025, she was suffering with lower abdominal pains and called her GP surgery, who said that her daughter was lying funny and prescribed her codeine. On Friday, she started losing blood while she was at home. It transpired that when she had called the GP, her placenta was rupturing. She lost over 4 pints of blood and nearly died. Luckily, the amazing staff at Burton hospital got her daughter out safely and stabilised Hayley, but after 13 hours, Evelyn sadly passed away with her mummy and daddy by her side.
Hayley was informed by the hospital that if her GP had seen her in person and examined her, they would have noticed what was happening, and her daughter would have stood a greater chance of survival. Because of the negligence she suffered, all she has left of Evelyn is a small box in the living room containing her ashes. I promised Hayley that at the right time I would mention Evelyn’s name in the Chamber, so that she would be remembered always in the records of Hansard.
No parent ever imagines that they will outlive their child. The loss of a baby is heartbreaking beyond words and a grief that shatters hopes and dreams for the future—the hope of seeing that child grow, thrive, learn and love, and the joy of watching them take their place in the world. All of those are stolen in an instant, leaving a space in the family that can never be filled. Brothers and sisters lose the chance of a lifelong companion. Grandparents lose the grandchild they had longed to cherish and spoil. Baby loss touches everyone and takes so much from so many.
My constituents and friends Suman and Jim Antcliffe have suffered the painful loss of two grandchildren: Lenny, who sadly passed away not long after a full-term birth, due to cord entanglement; and Bhai, whom they lost at 18 weeks’ pregnancy for a reason no one knows. Amid deep sorrow, Lenny and Bhai’s incredible parents, Miriam—Suman and Jim’s daughter—and her husband Roy, founded Lenny’s Legacy. They have published an e-book about the physical recovery after a baby’s death, which includes information on postpartum recovery, breastfeeding and lactation. Perhaps our NHS could look to fund that in hard copy, so that hospitals could to give it to parents who have suffered that loss.
Soon after I became the Member of Parliament for South Derbyshire, the team and I were contacted by Alex and Kirsty Garner, a couple who had suffered a loss. They felt that there was not the support they needed, so they created that support with a group called Our Little Angels in Swadlincote, run by parents, for parents. My team and I were honoured to help them secure the funding for that. I promised Alex and Kirsty and other parents who have walked this painful path that I would mention their babies’ names in the Chamber. I may go slightly over the one minute I have left—I apologise for that, Madam Deputy Speaker—but it would be wrong of me not to call them by name now. We have Hayley Johnson and John Haddon and baby Evelyn; Miriam and Roy Prestwich and babies Lenny and Bhai; Kirsty and Alex Garner and baby Harry; Ames and Graham Silcock and their babies Olivia, Teddy and Ava; Gina and Adam Deacon and baby Poppy; Jaimee Long and Owen Archer and babies Arlo and Ava; Rebekah Wykes and Matthew Buckley and baby Jacob; Chelsea and Steve Cooper and babies Flower and Blossom; Nicolle Taylor and Peter Summerbell and baby Ariya; Rachel and Leigh Brassington and baby Archie; Hayley and Anthony Dawe and twins Finley and Darcie; Millie Garbutt and Luke Lenton and baby Lenton; Katie Garner and Callum Charman and baby Charman; Kirstie and James Palmer and baby Palmer; Amie and Connor Chinnery and baby Noah; Bev and Oliver and baby Alister; Beth Milnthorpe and Craig Timbrell and baby Timbrell; Charlotte Atherton and Callum Keyte and baby Wyatt; Bec Barker and baby Alister; Bec and baby Maisie; Paula Ann Haddon and her baby; and Lorinda Brownhill and Adam Townsend and baby Alfie.
To every family who has lost a baby, your grief matters and your children matter. This week, we light candles and wear ribbons to remember them, and to remind one another that love, even in loss, endures.
Lizzi Collinge (Morecambe and Lunesdale) (Lab)
I speak with a number of hats on: as the MP for Morecambe and Lunesdale, representing all my constituents who have lost babies in pregnancy; as a mum of two children; and as a woman who has lost two much-wanted pregnancies. I want to use my place here to shine a light on the pain that families are feeling due to baby loss, and the steps that the Government can take and are taking to help them, from enforcing a duty of candour on public bodies to giving bereavement leave to parents who have lost a baby before 24 weeks of pregnancy.
First, I welcome the national maternity investigation. I thank the Secretary of State for his attention to it, and for listening to harmed families. I want to emphasise that, on the whole, maternity care in this country is safe, but where it is not, strong action must be taken. I was relieved to see that my local trust, Morecambe Bay, will be part of the national investigation, not least because of the experiences of my constituents Ryan and Sarah, whose baby Ida was born in 2019 and died seven days after. Ida died because of failings in her care. I know, as Ryan and Sarah do, that mistakes happen—healthcare workers are human—but they have had to fight every step of the way to get the truth about their daughter’s death, which feels so inhumane. After the hospital trust’s completely inadequate internal investigation declared there to be no care issues and Ida’s death was graded as “moderate harm”, Ryan and Sarah had to approach a senior coroner to get a full inquest. It was only at that inquest, five and a half years later, that the trust accepted that its failings had led to Ida’s death.
The thing that breaks my heart is that those failings had already been identified: the Kirkup report identified major failings, which were meant to have been fixed. I first became involved in maternity advocacy in Morecambe Bay after the pretty awful birth of my first child. There was a lot of activity in the trust in response to the Kirkup findings, and I do believe that improvements were made, but two things never went away, and I think they are still harming families to this day.
The first thing that I want to highlight is the ideological belief that certain types of birth are superior to others. We hear talk of “normal” or “physiological” birth. The belief that that is somehow superior to a birth with intervention still harms people today. The second thing is the organisational culture that led to a care organisation responding to a baby’s death not with care, respect and humility, but with a gross failure to investigate, a gross failure to act with decency and kindness, and a gross lack of transparency.
Finally, I want to mention a constituent who came to my surgery a few weeks ago. Her stepdaughter was born sleeping many years ago, and she and her husband recently found out that she was buried in a mass public grave. They know the location where she was put to rest, and they really want to put a marker directly on the grave site, but apparently that is not allowed under local council rules. They are puzzled, as am I, as to why marking one baby’s death is somehow disrespectful to the other babies who lie in that mass public grave. I am working with my constituent to try to address that.
I am glad that the pain that families feel across our country is being recognised in this place today. We cannot let more babies die preventable deaths. We cannot let those losses go unacknowledged. I thank Members in the Chamber today for their work.
Susan Murray (Mid Dunbartonshire) (LD)
I thank the right hon. and hon. Members who secured the debate, as well as those who have shared their story. Every Member here agrees that the tragedy of losing a child is one of the greatest anyone can face, yet sadly it is all too common an experience; nearly half the population has either experienced the loss of a baby or knows someone who has.
It is with that deeply saddening thought in mind that I want to pay tribute to the tireless campaigning of Louise Caldwell in Scotland. After her experience of loss, she has influenced the Scottish Government’s strategy on baby loss. She has also succeeded in getting two baby loss units opened—at Wishaw hospital, in the constituency of the hon. Member for Motherwell, Wishaw and Carluke (Pamela Nash), and at Gilbert Bain hospital, with the support of my right hon. Friend the Member for Orkney and Shetland (Mr Carmichael) and our Liberal Democrat colleague Beatrice Wishart MSP. Those dedicated facilities allow mothers, fathers and families to grieve the loss of their baby in the most dignified and compassionate environment we can provide. I realise that this is a devolved matter, but I am sure that everyone in the Chamber understands the need for baby loss units and, along with them, compassionate labour rooms, away from the sounds of happier arrivals, for those all over the UK who experience delivering a sleeping angel.
While dedicated spaces are essential, we must also look at prevention. I find it deeply concerning that we continue to see repeated failings in maternity services. The Ockenden report on Shrewsbury and Telford, and the East Kent inquiry, highlighted systemic issues, including inadequate equipment, crumbling maternity wards, weak incident management and slow triage of urgent cases.
Furthermore, it is unacceptable that when my hon. Friend the Member for North Shropshire (Helen Morgan) asked the Department about progress regarding implementing the recommendations of the report, the answer implied not only that Ministers could not confirm delivery but that they had no mechanism to measure any progress made. That is simply not good enough, as the hon. Member for Rossendale and Darwen (Andy MacNae) highlighted. We need a national strategy that extends across all four nations, with clear baselines to ensure that mothers and babies receive the care they need and deserve. We need clear and transparent measures to ensure that standards are being met and to identify when they are not, because ultimately this is about protecting women and babies.
Sarah Smith (Hyndburn) (Lab)
Baby Loss Awareness Week is an opportunity for those affected by baby loss to remember and commemorate their babies’ lives and to highlight this deeply important subject. I am glad to see that we are doing just that in this debate, and has it not been possibly the best of our Chamber? I pay particular tribute to my hon. Friends the Members for Sherwood Forest (Michelle Welsh) and Rossendale and Darwen (Andy MacNae) for their very moving tributes, which started the debate.
Every year in the UK, as we have heard, thousands of families are affected by the heartbreak of baby loss. It is a grief that is often invisible to the outside world and too often a silent trauma, but for those living with it, the impact is lifelong. It touches every aspect of their being —emotional, physical, psychological and spiritual—and the structures must be in place for those who need support following the loss of their baby.
In my constituency of Hyndburn and Haslingden, the staff at East Lancashire Hospitals NHS trust do a fantastic job. They are signed up to the national bereavement pathways, but as we have heard, that is not a statutory requirement. I hope that the Secretary of State will consider making it a statutory requirement, so that access to psychological support is not a postcode lottery. With rising demands on maternity services, additional staffing is required so that every family who experiences birth trauma or baby loss can get the support that they need.
Thanks to some work that was undertaken by a number of leading experts at the University of Lancashire, including my brilliant constituent who is the perinatal mental health lead at East Lancs Hospital trust, Clare Yates, they developed an evidence-based birth and reproductive trauma debrief service that has been designed to ensure that every family could receive that support across East Lancashire, and it is ready for implementation. Given the limited resources and staffing, we have not been able to roll it out, but I hope that events such as today’s debate and the renewed focus on this issue from the Secretary of State might change that, so that the enhanced service can be offered to give the care and support that families desperately need.
Up and down the country, there are competing uses for maternal funds, with the result that, unfortunately, trauma, mental health and bereavement support often get overlooked, with greater importance given to physical health. Holistic baby loss trauma services make a profound difference, and we must recognise that supporting families through baby loss is absolutely essential care, so I urge the Secretary of State to do all he can to ensure the highest possible level of care in maternity services, including in the devastating circumstances of miscarriage or baby loss, and to ensure that that support is there for everyone who is unfortunate to experience it.
Bell Ribeiro-Addy (Clapham and Brixton Hill) (Lab)
I know that this debate is not an easy one for those of us participating and for the campaigners, activists and bereaved parents who are listening, but it is nevertheless vital and I am very thankful that it is taking place. I begin by commending all those, including my hon. Friends who have led this debate in the House and beyond, who have found the courage to stand up and speak about their experiences of baby loss.
I know from personal experience just how difficult that is to do—to reopen that wound and to relive that pain in public. Every story of baby loss, told or untold, is worthy of our compassion and respect, and I say that because after the occasions when I have shared my own experience, I have been met time and again with questions: how long ago was it, how far along were you and how do you know that racism was a factor? Perhaps some of those questions were asked in innocence, but let me tell you how it made me feel: as if people were measuring my loss, weighing my grief and deciding how much pain I was allowed to feel, and as if there were a scale for sorrow. It is not one-sided. I have spoken to women who, after hearing my experience, have opened up about their own and ended by saying that their experiences were not “as bad” because mine was a late-term stillbirth and theirs was a miscarriage. That broke my heart because it is not true. To all those who experience baby loss in whatever form, your experience matters, your grief matters and your loss matters. That is why Baby Loss Awareness Week is about all forms of pregnancy and baby loss—it is not the loss Olympics. Whether it is an abortion someone had to have, an ectopic pregnancy, an early or late miscarriage, a stillbirth or neonatal death, every single one of those experiences deserves recognition and care. No one—absolutely no one—has the right to quantify your loss.
For those of us who have shared our stories, we do not do it for validation or pity; we share them so that others who have endured baby loss know they are not alone, no matter when or how they lost their baby. We share them as a call to action because in a country like ours, the figures surrounding maternal mortality and baby loss should never ever be acceptable.
Earlier this year, I led a debate in recognition of Black Maternal Health Awareness Week, during which I highlighted the racial disparity in maternity care and the fact that it has gone down. Black and mixed heritage women are now three times more likely to die during pregnancy and childbirth, down from five times when I first launched the APPG for black maternal health, and Asian women are twice as likely. Regretfully, this decline is not necessarily something to celebrate, nor is it due to improvements in maternity care for black women. It is because the UK’s overall maternity mortality figures are rising. More women and babies are dying in the UK now than in the last two decades. Black women are likely experiencing even further deterioration.
The latest findings from MBRRACE-UK reveal a widening divide in neonatal death rates between the UK’s most and least deprived areas. Black and minority ethnic people are 2.5 times more likely to live in relative poverty and 2.2 times more likely to live in deep poverty. In plain terms, poverty and deprivation are costing newborn lives, so the combination of socioeconomic inequalities and institutional racism has a double impact on black women and their babies’ experiences of maternity care and its outcomes. The data also shows a sharp rise in stillbirths among babies of Asian heritage, and black babies remain twice as likely to be stillborn. Urgent, targeted action is needed to tackle these deaths and health inequalities and prevent avoidable deaths.
The new report from the Health and Social Care Committee on black maternal health shows that the outcomes of maternity care are shaped by systemic failings in leadership, training, data collection and accountability. The Secretary of State will know that when the Government promised to find a way forward, I was proud, and when the Government made it a manifesto commitment to set a target to end disparity in maternity care, I was prouder, but this has not happened. The NHS 10-year plan has come and gone without a specific plan for racial disparities in maternity care. If that was not the time to announce a target, when will it be?
Amanda Hack (North West Leicestershire) (Lab)
I thank my hon. Friends the Members for Rossendale and Darwen (Andy MacNae) and for Sherwood Forest (Michelle Welsh) and the right hon. Member for Godalming and Ash (Sir Jeremy Hunt) for securing this important debate during Baby Loss Awareness Week to give those who have experienced pregnancy and baby loss that voice and the feeling that they are not alone. When I had my son 18 years ago, I was lucky to have the support of five other mums during those first tricky years with our babies. However, sadly for three of those mums, they had also suffered the heartbreak of a miscarriage. For them, they had support from each of us. It was not a silent subject; they could talk and share about their loss. However, at the time, I remember thinking about how their partners were coping with that loss without having that same support network. It is so important that both parents have the support they need after such devastating bereavement, such as from organisations like Ashby Sands United in my constituency. Ashby Sands is a football team for men who have suffered the devastating loss of a child or a miscarriage. One of their members told me at a recent event,
“Sometimes I don’t need to say anything, the lads know how I feel. The football isn’t always good, but the friendship and the support I get from them is what I cherish.”
In this debate, it is experience that matters, and my constituent Sarah has asked me to share these words:
“Losing a baby is an incredibly difficult and isolating time, to then learn that our baby’s death was preventable is just soul destroying. Feelings of guilt and regret—and whether it could have been prevented. Mistakes were made in my pregnancy, incorrect measurements were recorded, follow up scans were not arranged, our care was mismanaged. The hospital admitted if these scans had happened and measurements were recorded accurately; we would have had a different outcome. At one of our most exciting and vulnerable times of our lives, we put our trust and care into the hands of strangers. Trusting that we will be treated with the dignity and respect that we each deserve.”
Sarah stressed the need to drive changes in teaching and learning to make maternity and childbirth safer for all. She welcomes the rapid review and its potential to bring about much-needed changes to maternity care across the UK, but she stresses the need for a trauma-informed approach to the consultation. Those who have experienced that trauma will need support to engage. Will the Secretary of State say more about how trauma will be considered in the review?
I also welcome the rapid review. My constituents can have their babies in Nottingham, Leicester or Derby. As a former Leicestershire county councillor, I sat on the health overview and scrutiny committee. The saddest report that I requested was about maternity healthcare and baby loss. As Nottinghamshire was a neighbouring trust, I wanted to understand the situation in Leicestershire. We received a report on babies who died in childbirth. In a six-year period, seven babies had died and seven families had dealt with that devastating loss. In line with the statistics on late-term loss, six of the mothers were black or Asian. Data indicates that neonatal mortality rates for black and Asian babies are over 50% higher than for white babies. Will the Secretary of State set out how he will work towards eliminating those stark inequalities in maternity and neonatal outcomes based on ethnicity and deprivation?
I have considered a number of reports on maternity and have a few reflections. Maternity healthcare needs to be considered as healthcare. I have heard phrases such as “pregnancy isn’t an illness” and “giving birth is natural”, but I have also heard from mothers who felt that they were not listened to and felt powerless. Every stillbirth, neonatal death or infant death is a tragedy. We must make efforts to prevent them from happening. I know that, together, we will fight for justice for those who deserved just a little bit more time.
Jo White (Bassetlaw) (Lab)
Tonight I will talk about Laura Corcoran, an inspirational woman who lives in my Bassetlaw constituency. When a scan showed no heartbeat, she was sent home to wait two weeks until the delivery of her baby. She remembers asking, “How do I collect my baby?” She said that the thought of flushing it down the toilet was something that she did not want to countenance. With no information, Laura was left feeling isolated and alone, and she had to rely on what she had to hand. She resorted to using a sieve and a plastic takeaway food box.
Laura said:
“People are given a test tube to collect urine samples, but when I was told to collect my baby, I was given nothing. I was angry.”
During her recovery, she channelled her anger and used her engineering skills to design a device that she has named the “miscarriage cradle”. It hooks on to a toilet seat and collects and seals the remains so that they can be taken safely to hospital. Her mission is for every woman to have better control, giving them a choice of managing the miscarriage at home.
Laura has begun actively promoting the miscarriage cradle in the NHS, and the Royal Liverpool university hospital was the first to adopt it. In a statement, the hospital said that one recommendation of the 2023 pregnancy loss review was for NHS trusts to provide women experiencing pregnancy loss with a compassionate clinical care kit, and the miscarriage cradle ticked all the boxes. The statement also noted that, in the tough world of hospital finances, the trust will save money, because when women have the option of managing a miscarriage at home, savings are made on staffing and bed space costs. So far, 13 trusts have adopted the miscarriage cradle, and the 14th has just got approval.
The Northern Lincolnshire and Goole NHS Foundation Trust says:
“Going through a miscarriage is one of the hardest experiences that anyone can face. It’s raw, painful and often feels isolating. This miscarriage collection kit is more than just a product—it’s a small but powerful way to help women hold on to their dignity in a moment that can feel so overwhelming.”
Those words define Laura’s mission. Her focus is for every NHS hospital trust to have miscarriage cradles in stock. She has asked me to raise awareness of her cradle, and she also asks whether she can meet the Secretary of State to discuss this with him. She also asks Members to sign my early-day motion on baby loss kits.
Finally, I take this opportunity to thank JOEL The Complete Package, a Bassetlaw charity, for its support for families experiencing such crises, and for its fundraising initiative, which has ensured that there is a room at Bassetlaw hospital for parents facing such a difficult time in their lives.
Several hon. Members rose—
Madam Deputy Speaker (Caroline Nokes)
Order. I ask hon. Members to take their lead from the hon. Member for Bassetlaw (Jo White) so that I can get everybody in. If they kept their speeches to three minutes, that would be very helpful.
Adam Thompson (Erewash) (Lab)
I thank all hon. Members in this evening’s debate, particularly those who secured the debate but also the many who shared their incredibly powerful stories.
We have heard from several Members about the failures at Nottingham university hospitals NHS trust to keep mothers and their babies safe. In 2019, my constituents Carl Everson and Carly Wesson were expecting their daughter Ladybird. During the pregnancy, Carl and Carly were told that Ladybird had a fatal chromosomal abnormality—trisomy 13, also known as Patau’s syndrome. They were told that she was incompatible with life and that if she survived the pregnancy she would live only briefly and in severe pain.
Faced with that devastating prognosis, Carl and Carly made the agonising decision to end their pregnancy. Two weeks after Ladybird’s funeral, they were told during an appointment that the long-term culture test showed a normal female carrier type. There was no evidence of Patau’s; Ladybird had been a healthy baby. Carl and Carly later learned that Ladybird’s death was not inevitable. It was the result of a misdiagnosis and a failure to follow national guidelines around abortion.
The Abortion Act 1967 requires two doctors to form an opinion in good faith, but Carl and Carly learned through their investigations that the second medical practitioner was, at best, used as a rubber-stamping exercise. That failure led to the loss of a very much loved and wanted child. Carl and Carly have spent six years fighting for answers—six years navigating a system that should have protected them. Today they continue their fight for answers and are working every day to ensure that guidelines around abortion are properly followed by doctors and that laws are updated if required.
The second family that I have worked closely with on this issue over the past year have been the Sissons. Sarah and Tony Sissons did not lose their son Ryan—indeed, Ryan joins us in the Gallery today—but every day they mourn for the man Ryan could have become. Ryan was born healthy, but just three days after his birth, a sequence of errors and neglect at Nottingham city hospital caused him to suffer a catastrophic brain injury. Consequently, Sarah and Tony were told that Ryan would never be able to walk or talk.
Sarah was just 19 years old, and was given no help to navigate her drastically changed life; instead, the Sissons were handed a leaflet about adoption. I understand that that leaflet is still framed on a wall in their house. Ryan told me today about how he learned to march in the sea cadets—he showed me in Westminster Hall and he was damn good at it; he did a pretty good job of walking and talking as far as I was concerned.
Last month Ryan turned 18, but he did not go out with his friends to the pub to celebrate. He is not applying to universities or doing an apprenticeship. Sarah and Tony are preparing their home so that Ryan can live with them for the rest of their lives. Sarah gave up her career to care for Ryan. She spent his childhood fighting to get that care, battling with the NHS and local authorities, attending endless appointments and mourning the big life milestones that Ryan never really got to reach.
Ryan is the oldest child being considered in the Nottingham Ockenden review. Among the nearly 2,500 families affected, Ryan is the first child. Ryan should not have been the first of thousands. The failures of Nottingham university hospitals NHS trust should have been learned long ago, but they were not. Those responsible have not yet been held accountable. Ryan should have had the chance to enjoy a happy, healthy childhood. Ladybird should be with her parents, far away from a House of Commons debate on baby loss.
Despite the efforts made today by myself and colleagues, it is not possible to put into words how the failings of the NUH trust have profoundly impacted so many lives in our community. I hope, deeply, that this Government are going to provide the justice that they deserve.
Several hon. Members rose—
Madam Deputy Speaker (Caroline Nokes)
Order. There is now a formal three-minute time limit.
Amanda Martin (Portsmouth North) (Lab)
I rise to speak about baby loss on behalf of those affected—those who I know and love, and those who I do not know. This tragedy touches far too many families in Portsmouth North and across our country. We have heard today how each year in England and Wales, tragically, around 2,500 babies are stillborn and a further 1,600 die within their first year of life. Behind every statistic is a grieving family—mother, father, grandparents, aunties, uncles, cousins and siblings—whose world is changed for ever.
Around 2,000 babies are born in Portsmouth each year. While outcomes have improved, we still see the deep inequalities that drive baby loss, and babies born in our most deprived communities are twice as likely to die before their first birthday than those in our wealthiest communities. Many of our maternity teams are working tirelessly to change that. At my hospital, the Queen Alexandra hospital, the maternity service has earned a UNICEF baby-friendly gold award, a national HSJ digital award and an NHS parliamentary award for innovation and compassionate care—proof that the possibility of dedication and excellence can and does exist.
However, such excellence should not be a postcode lottery; it should be national and available for all. We have the knowledge to prevent many of these tragedies. We have had inquiries that have produced recommendations and actions about early, informed and accessible antenatal care, tackling health in pregnancy, supporting maternal mental health, accountability, transparency, openness and addressing inequalities, and listening to women and families about their experiences, to ensure that their birth choice is right for mum and baby, free from pressure and prejudice. Services must be properly funded, staffed and joined up.
When nothing can be done and a loss occurs, compassionate bereavement support is vital. Parents tell me that small acts of care, including a quiet room, a midwife who listens, a support group for all the family, the use of language—that it is a baby loss, not a miscarriage —and the opportunity to talk and be heard, can all make a difference. However, like maternity provision, bereavement support varies widely and too many families are left to cope alone, often in silence.
This week, as we mark Baby Loss Awareness Week, we must stand with every parent who lights a candle, remembers a name or holds in their heart the baby they never got to take home or who was not physically in their lives forever, but who will always be a part of their family. To those families, I know we all say, “You are not alone, your babies are not forgotten and your courage gives meaning to this work and to our debate.”
As a Government, we must work with local NHS leaders, public health teams and charities. We cannot talk about breaking down barriers to opportunity if we do not do that in our maternity services. Baby loss is not inevitable, but it is a challenge that we, as a Government, can and must meet. With compassion, we must have action.
Mrs Sureena Brackenridge (Wolverhampton North East) (Lab)
I thank every Member from across the House who has shared their personal experience and those of their constituents. I also thank the families who have been listening to the debate in the Gallery.
From what has been shared so passionately, it is clear that not every family faces the same risks or receives the same care. The latest data from MBRRACE-UK—Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK—has already been shared, but I feel that I must repeat it, as it is so deeply concerning. It shows that babies of black ethnicity are more than twice as likely to be stillborn as babies of white ethnicity. Neonatal mortality rates among black and Asian babies are over 50% higher than those among white babies, and babies born to mothers in the most deprived areas are twice as likely to die in the first month of life than those in the least deprived areas.
Access to bereavement care is also unequal. The national bereavement care pathway sets out what good care should look like, but voluntary adoption, stretched staff and a lack of time for training mean that too many families miss out. When mental health support is needed, it is even harder to access. Over 80% of bereaved parents report needing psychological support, yet only half are able to access it through the NHS. In particular, fathers and partners are forgotten far too often.
I thank the Secretary of State for being in the House to listen to the debate. Will the Government commit to eliminating inequalities in maternal and neonatal outcomes based on ethnicity and deprivation? Will they ensure that every bereaved family—wherever they live and whatever their background—can access high-quality bereavement and mental health care? Will every NHS professional who supports those families be given the training and time they need to do so with confidence and compassion?
I welcome the steps that the Government have taken, including extended baby loss certificates and the improvements to parental bereavement leave set out in the Employment Rights Bill. However, Members from across the House, like families across the country, are calling for the compassionate, consistent and equitable care that every bereaved family deserves.
Michael Payne (Gedling) (Lab)
I rise, in Baby Loss Awareness Week, to pay tribute to the far too many families in Gedling and Nottinghamshire who have suffered the devastating loss of their babies in circumstances that were entirely avoidable. They placed their trust in a system that should have protected them, and that system failed them.
The Ockenden review of maternity services in Nottingham is now supporting 2,500 families who have been affected by neonatal deaths, injuries, stillbirths and maternity deaths. Many of them were failed by the NMC, failed by the GMC, failed by the CQC and failed by our NHS. Regulation must be overhauled, and accountability must improve.
The mothers and fathers who have come forward in Gedling and Nottinghamshire have shown extraordinary dignity, courage and perseverance in the face of heartbreak that most of us can barely begin to comprehend. Yet even in the face of unspeakable loss, each and every family I have met in Gedling and Nottinghamshire who have lost a child or suffered harm during birth have reminded me that light always shines brightest in the darkest places. In the depths of their grief, their pursuit of truth and change honours their children’s memory and stands as a beacon of tremendous humanity and hope.
I want to take a moment to pay a special tribute to the incredible charities, volunteers and support organisations who walk alongside bereaved families day in, day out. They bring comfort where it is needed most, and we all owe them a tremendous debt of gratitude.
In speaking of courage and compassion, I also want to take a moment to thank my friend and neighbour, the Member of Parliament for Sherwood Forest, Michelle Welsh. Long before she entered this place, Michelle walked side by side with Nottinghamshire families through years of anguish and struggle, standing shoulder to shoulder with them when few others would. Just 37 days ago, she suffered her own loss with the passing of her beloved dad, who taught her to fight always against injustice, wherever she found it. Just days after losing her dad, she was back in Parliament, meeting bereaved maternity families. In thanking Michelle for her leadership today—
Madam Deputy Speaker (Caroline Nokes)
Order. The hon. Gentleman will know that we do not refer to Members by name in this place. That is the third time he has referred to the hon. Member for Sherwood Forest by her name.
Michael Payne
My apologies, Madam Deputy Speaker.
In thanking my hon. Friend the Member for Sherwood Forest (Michelle Welsh) for her leadership today, I want to say that her dad would have been so incredibly proud to sit in the Gallery today to see his little girl in this Chamber using the privilege of her platform to fight for those who have been failed and suffered the most unimaginable loss.
I also pay tribute to the families who have campaigned for years for change and justice. We owe them far more than sympathy. We owe them justice, and we owe them truth.
Madam Deputy Speaker
Order. The hon. Gentleman has had more than three minutes, and I want the Front Benchers to have some time to respond. I call Dave Robertson.
Dave Robertson (Lichfield) (Lab)
I place on record my thanks to the co-sponsors of today’s debate and to all Members who have shared their personal experiences. It has been a very difficult debate for many of us on such an important but such a difficult subject.
Like many Members today, I am here to speak on behalf of my constituents. Tim and Hannah lost their son Zack when he was just 14 hours old. Zack’s inquest found that there was a total and complete failure in his care. I genuinely do not know how parents can receive an inquest verdict like that and find the strength to put themselves back together, but Tim and Hannah did—I am sure that is something we will see in many of the people in the Gallery today. They found the strength to put themselves back together and start looking to what comes next.
Zack’s story is that he caught a group B strep infection as he was born. It is incredibly common—20% to 40% of women have it on any given day—and it is generally symptomless in adults, but if it passes from mum to baby during labour, it can be fatal. On average, one baby a week in the UK dies of a strep B infection. Group B strep is common in mums and highly dangerous to babies, but the UK does not routinely test for it during pregnancy. Instead, we rely on risk factors to identify expecting mums who have it, and too often—as in Zack’s case—that approach is not working.
I am pleased that a major trial, the GBS3 trial, is under way to look at whether we would be better off routinely testing, and is due to report later this year. It is no overstatement to say that that trial is a once-in-a-lifetime opportunity to look at our approach to the safety of babies in this situation. I really hope that it reports and moves us towards a situation in which we can routinely test for this condition during pregnancy. The gold standard test costs just £15, and can save lives—potentially, a life a week. We must do all we can to protect babies like Zack and ensure that no more parents go through what Tim and Hannah have had to.
Sean Woodcock (Banbury) (Lab)
It is a real privilege to have the opportunity to speak in this debate, particularly after so many powerful and profound speeches and interventions from Members across the House. I want to share the testimony of a constituent who has endured an experience that affects many families, yet receives very little attention: hypoxic-ischemic encephalopathy, or HIE. Her son survived a HIE event during his birth. HIE is a brain injury caused by a lack of oxygen or blood flow, which can lead to developmental delays, intellectual and physical disabilities and—tragically—in one in five cases, death. Some of these complications can remain hidden until school age.
My constituent had never heard of HIE at the time, nor had I prior to her contacting me, but it is an all-too-common condition that affects three to four births out of every 1,000. In her son’s case, it resulted in mild cerebral palsy. She was supported by a wonderful charity called Peeps, which highlights that families affected by HIE often feel that they do not belong in a baby loss space. Many of those families experience birth trauma, PTSD and complicated grief. While charities such as Peeps offer support to anybody affected, NHS mental health support can often be restricted to just the mother. This leaves fathers and partners—who are also deeply affected—to cope alone. Support must and should be for the whole family.
Peeps also emphasises the significant gaps in long-term support, especially for families whose children survive but face lifelong, severe disabilities. They are left to navigate complex needs for years after the initial intensive care ends. The trauma is compounded for families whose event may have been avoidable. A study in Finland between 2005 and 2024 suggested that a fifth of all such cases could have been prevented, or at least could have benefited from preventive measures. This compounds the trauma of affected families and underscores the importance of absolute honesty and systemic learning in our NHS services.
Additionally, HIE is not always recorded consistently in NHS systems or statistics, making it harder to advocate for policy change and obscuring potential disparities in outcomes, which we know exist for stillbirths and neonatal deaths. We must listen to brave parents such as my constituent and fantastic charities such as Peeps and ensure that HIE is no longer misunderstood or unheard of in conversations about baby loss. We owe these families recognition, compassionate care, and a commitment to address the lack of consistent data that makes it so hard for them to advocate for change.
Madam Deputy Speaker (Caroline Nokes)
Order. That brings us to the Front-Bench contributions, which will perhaps be in the region of eight minutes each.
Alison Bennett (Mid Sussex) (LD)
The hon. Members for Rossendale and Darwen (Andy MacNae) and for Sherwood Forest (Michelle Welsh) and the right hon. Member for Godalming and Ash (Sir Jeremy Hunt) must be thanked, not just for securing this debate to mark Baby Loss Awareness Week, but for their tireless advocacy to improve maternity services across the United Kingdom—work that they have been carrying out for many years.
The pain of baby loss is multifaceted. It involves not only the unimaginable grief that accompanies losing a baby, but the emotional and psychological suffering that comes with facing the prospect of a life without your child—a future completely different from the one you had hoped for. Losing a baby can be loud, fast and chaotic, but it can also happen quietly—almost unnoticeably. Some parents arrive home from the hospital to a wardrobe full of baby clothes and piles of newborn toys, but an empty cot. Other expectant mothers may wake up in the morning excited to be another day closer to their baby’s arrival, only to find out that it was not meant to be.
Half of adults in the UK said that they or someone they know had experienced pregnancy or baby loss. According to Sands, every day in the UK 13 babies die shortly before, during or soon after birth. These families, as we have heard tonight, have to try to pick up the pieces, maintain their relationships, work and continue with daily commitments, all while tackling the emotional and often physical trauma of their experiences. They often walk that path alone, feeling like there is nobody they can speak to about their indescribable grief, or that they should not speak about it, as though they themselves have somehow failed. That is not the case, and no woman should have to suffer in silence.
In the case of my constituents, Hannah and Simon, not only did they have to come to terms with the fact that they would not be taking their baby boy, Austin, home from the hospital, but they had to face the reality that this tragedy was avoidable and that their baby would have survived, had the trust recognised and responded to concerns identified in the foetal and maternal monitoring. Hannah and Simon are not the only ones. Connecting with other parents in Sussex resulted in them hearing stories from other families whose experiences were concerningly similar to their own.
Between 2019 and 2023, the University Hospitals Sussex NHS Foundation Trust paid £58 million in compensation for 60 medical negligence claims related to maternity and obstetric care. That is the second-highest amount of compensation and the third-highest number of claims across all NHS trusts in England. That, and Hannah and Simon’s story, points to a larger systemic problem at the heart of maternity care. It was clear then, as it is now, that successive Governments have been asleep at the wheel on maternity care, and it is the families at the heart of it who pay the price—families such as Hannah and Simon’s. Their baby Austin would have been starting school next year if things had been different, and their daughter, just three when her little brother died,
“should not have to continually ask us why her friends got to bring their siblings home, and she had to say goodbye instead.”
That family, like too many across the country, deserved better. Now, they themselves are calling for change so that no one else misses out on a lifetime of memories with their child as a result of avoidable mistakes.
As part of her inquiry into maternity care, Donna Ockenden provided a blueprint—a starting point from which we could put an end to this scandal, make maternity care fit for purpose and put an end to these unnecessary deaths. However, not only have the nationally applicable, immediate and essential actions of the Ockenden report not all been implemented, but the Government have dropped the requirement for every ICB to have a women’s health hub, and they have announced cuts to the national service development funding for maternity services from £95 million in 2024-25 to just £2 million the following year.
Is it any wonder, therefore, that the UK is underperforming compared with other OECD countries on infant and newborn mortality, or that, according to a Care Quality Commission report in September 2024, 65% of units are not safe for women to give birth in? We want our country to become the safest place in the world to have a baby, but that can only be achieved if accountability is taken for these failings, lessons are learned, and concrete steps are taken by the Government to put an end to this national scandal.
We have heard from a number of Members this evening about the impacts of deprivation and ethnicity on outcomes for maternity and for babies. The colour of someone’s skin, their bank balance or where they live should not be deciding factors in whether they and their baby live or die. Quite simply, maternity care should not be a lottery.
I very much welcome the Secretary of State’s presence this evening, and I endorse the comments made by the right hon. Member for Melton and Syston (Edward Argar) and my hon. Friends the Members for Horsham (John Milne) and for Chichester (Jess Brown-Fuller), who said that families who have lost babies through medical negligence need to be taken with the Government on this journey towards reviews. I think that the Sussex families would be furious with me this evening if I did not say to the Secretary of State that they are not happy with the way in which the reviews announced in July are going so far, so I urge him to do everything in his power to listen to the families and take them on that journey together.
Let me pose a question to the Secretary of State on behalf of Hannah and Simon. These Sussex families have waited over a year for the Government to appoint Donna Ockenden, the one person with a proven record of exposing failings and driving improvement. Thus far, their patience has been repaid with delay, confusion and avoidance. When will the Government act to stop these preventable deaths by appointing Donna Ockenden to lead the Sussex review, and by confronting what has become a national shame for our country’s children with a full public inquiry?
My hon. Friend the Member for Carshalton and Wallington (Bobby Dean) spoke movingly about his and his wife’s experience of miscarriage, and I endorse his call for mental health support following every miscarriage, not just after three.
Madam Deputy Speaker (Caroline Nokes)
Order. I am sure that the hon. Lady will want to conclude her remarks very quickly.
Alison Bennett
The theme of this year’s Baby Loss Awareness Week is “Together, we care”, and we do care. We care about all kinds of baby loss, and we care about babies like Austin. Hannah told me:
“We lost an entire lifetime. Our son never had the chance to grow up, to take his first steps, to speak his first words, to make friends”—
Madam Deputy Speaker
Order. The hon. Lady must have misunderstood what I meant by “quickly”.
Dr Caroline Johnson (Sleaford and North Hykeham) (Con)
Let me first draw Members’ attention to my entry in the Register of Members’ Financial Interests.
I congratulate my right hon. Friend the Member for Godalming and Ash (Sir Jeremy Hunt) and the hon. Members for Rossendale and Darwen (Andy MacNae) and for Sherwood Forest (Michelle Welsh) on securing the debate, and on their eloquent and thoughtful speeches. Behind the statistics that I will put before Members, as others have done today, are the broken families with a gaping hole in their lives and a pain that will never go away. There are so many unanswered questions. What would their first word have been? When would they have taken their first steps? Who would they have grown up to become? For families who have lost a baby, these questions, painfully, tragically, will never be answered.
I have been honoured to meet representatives of charities all of which are doing excellent work to support families who have been affected by baby loss, and campaigning for improved maternity services. I pay tribute to those charities—including Bliss, Sands and Tommy’s—and to the royal colleges, and I thank the families in the Maternity Safety Alliance for sharing their very personal and moving stories with me when the shadow Secretary of State and I met them recently.
The last Government worked hard to improve maternity services. A decade ago, my right hon. Friend the Member for Godalming and Ash, then Secretary of State for Health and Social Care, announced an ambition to halve the rates of stillbirths, neonatal and maternal deaths in England by 2030, and he made encouraging progress. The stillbirth rate fell by about 20%, as did the neonatal death rate, and the maternal death rate fell by about a third.
Gregory Stafford (Farnham and Bordon) (Con)
Does my hon. Friend agree that the introduction of baby loss certificates following the pregnancy loss review under the last Government was a vital step in recognising bereaved parents’ grief and offering support on their terms?
Dr Johnson
My hon. Friend is, of course, right. Those certificates have proved to be of great comfort to many. The hon. Member for Washington and Gateshead South (Mrs Hodgson) talked about her work in that regard, and I thank her for it. I am also grateful for the work of my former colleague Tim Loughton.
One of the reasons I went into politics is the fact that one can make more of a difference as a politician than as a single doctor alone. The changes made by my right hon. Friend the Member for Godalming and Ash mean that, by quite some margin, he has saved more babies’ lives than I have as a consultant paediatrician. I assure the Secretary of State that it is not flattery when I say that he has more capacity than any NHS doctor when it comes to saving babies’ lives. I am pleased to see him here at almost midnight; I know that he cares, and I know that, like all of us, he wants to stop the tragedies about which we have heard so much today. However, I ask him to consider, every day, whether he is really doing all that he can to maximise the opportunity that he has, and, in the spirit of constructive opposition, I have a few questions for him. He said he came in with a plan, but in fact he took a year to create the 10-year plan, which creates a maternity and neonatal taskforce that is tasked with creating another plan. I sincerely hope that it is a good plan, after all this waiting, but I do worry that it has lost time, so can he confirm when it will be published?
Staffing levels have been mentioned in many tragic incidents, and the Secretary of State has promised that he will train thousands of additional midwives. Looking at the figures, an average of 10 fewer students have been accepted on to midwifery degrees in England across his two years in office compared with 2023. Can the Secretary of State confirm when he expects to train the 1,000 additional midwives he promised in his manifesto?
The previous Government increased the number of medical school places and built five new medical schools. As those students begin to qualify, the specialist training places need to be expanded and British graduates need to be prioritised. The Secretary of State seemed to understand that at Easter, but what has he done about it? The applicant-to-place ratio has risen dramatically, and now strikes are threatened, which would threaten the care of women and babies across the country.
We know that reducing baby loss starts before a baby is conceived and that factors such as teenage pregnancy, smoking, obesity and sub-optimally managed chronic conditions increase the risk of stillbirth. We must systemically improve on factors that increase the risk of baby death. I welcome the fact that the Secretary of State has brought through legislation, introduced by the previous Government, to fortify bread flour with folic acid by the end of 2026. That will prevent 200 cases of neural tube defects a year and improve the health of pregnant women. I am also pleased to see that the Tobacco and Vapes Bill is gradually making its way through Parliament. However, given that the Bill completed its Second Reading in the House of Lords on 23 April and is not due to appear in Committee until 27 October—more than six months later—there just does not seem to be enough urgency in the Government’s actions. Can the Secretary of State tell us what he is doing to improve pre-conception advice and optimise the management of chronic conditions in women to reduce the risk of baby loss?
As an NHS doctor, I pay tribute to my colleagues, who welcome almost 600,000 tiny miracles into the world each year. However, as we have heard this evening, care does not always meet the highest standards and too often avoidable deaths occur. Can the Secretary of State assure us that the findings of the ongoing Ockenden review into maternity services will be swiftly acted on? Donna Ockenden’s 2020 review into maternity care at the Shrewsbury and Telford trust found that at least 201 babies and nine mothers could have survived had they had better care. From her report came a £95 million ringfenced fund to improve the care available for expectant mothers, but as we have heard already this evening, the Government have slashed that fund from £95 million to just £2 million, with the rest of the money siphoned off to England’s 42 integrated care boards.
The Government have also reduced ICB budgets and are forcing them to restructure. I am worried that this un-ringfencing of the budget, and the distracting reorganisation, will have a negative impact on efforts to improve maternity services. What is the Secretary of State doing to prevent negative consequences?
Neonatal care can be lifesaving. One in seven babies in the UK requires neonatal care, but unfortunately their fight for life is not always won, and 1,933 babies died in neonatal care in 2023. With that in mind, will the Secretary of State clarify the extent to which neonatal services will be included in the maternity and neonatal investigation due by the end of the year? How will the quality of neonatal care be assessed? The recent NHS estates review of maternity and neonatal care did not appear to include parental accommodation, yet many parents find that their babies are transferred miles away for specialist care. May I urge the Secretary of State to recognise the value of this accommodation and make sure it is widely available?
As many Members have mentioned, black and ethnic minority women are more likely to suffer baby loss or maternal death. Can the Secretary of State update us on what progress he has made on his Government’s manifesto promise to close the maternal mortality gap for black and Asian women?
In the decade since the previous Government launched ambitions to improve maternity safety in the UK, the number of stillbirths and neonatal deaths has reduced by almost a quarter, and the number of maternal deaths has reduced by around a third. These are encouraging signs, and they show good progress. We must build on these achievements, but there is so much more work to be done. Today we have heard many stories of loss and of care failures. Only action will turn the page on baby loss. We all wish for improved maternity and neonatal care, but the Secretary of State is the man with the levers to make that happen—the levers to save hundreds of lives. I urge him to use them urgently.
The Secretary of State for Health and Social Care (Wes Streeting)
I thank all right hon. and hon. Members who have taken part in this extremely powerful debate. I thank my hon. Friend the Member for Rossendale and Darwen (Andy MacNae), the right hon. Member for Godalming and Ash (Sir Jeremy Hunt) and my hon. Friend the Member for Sherwood Forest (Michelle Welsh) for securing the debate, and the Backbench Business Committee for granting it.
Before I get into the substance of the debate, since this is Baby Loss Awareness Week, I want to put on record my thanks to the all-party parliamentary groups on baby loss, on maternity and on patient safety for their work in raising awareness; and charities such as Tommy’s, Sands, the Miscarriage Association and Bliss, which give bereaved families a voice and incredible support, and which deserve special recognition. I am extremely grateful to Members from across the House who have named local charities, run by those—often with lived experience—who play such a crucial role in improving services, so that others do not have to experience the torture that they have experienced.
It is such organisations that drove the adoption of baby loss certificates, introduced by the last Government and expanded by this one. I, too, thank Tim Loughton for his work, and my hon. Friend the Member for Washington and Gateshead South (Mrs Hodgson) for her leadership in this space. Not everyone will choose to have a certificate, but the option is now there for all parents who have experienced losing a pregnancy to have that loss recognised officially. I know that this has meant so much to those who have taken up that option, and to those who are providing the service, particularly staff in the NHS Business Services Authority, who have shared with Ministers their pride—many of them having that experience of loss themselves—of being part of the solution. I am of course delighted that the Government in Wales have also taken up this option.
Given the time available, there is simply no way of doing justice to the contributions that we have heard from Members across the House and the stories that they have shared with us. However, if there is one thing I have learned in my time as Secretary of State working on these issues it is that words will not do any justice to these families. What people want to see is action, and what they need to experience is justice.
I really do want to say a heartfelt thank you to Members across the House who have had the courage to share their personal stories. In particular, my hon. Friend the Member for Rossendale and Darwen, by talking about his daughter Mallorie, has given a voice to many fathers and partners who too often feel airbrushed from the conversation and absent from consideration. I think it is very poignant that he opened the debate for us this evening.
This is no exaggeration, but my hon. Friend the Member for Gedling (Michael Payne) talked about the leadership of my hon. Friend the Member for Sherwood Forest, and it is truly extraordinary that, in the aftermath of such an awful bereavement with the loss of her father, she was back to work in a matter of days, so that she could be there with families in Nottingham to support them in their ongoing campaign for justice.
Of course, my hon. Friends the Members for Sheffield Hallam (Olivia Blake) and for Clapham and Brixton Hill (Bell Ribeiro-Addy) and the hon. Member for Carshalton and Wallington (Bobby Dean) all shared their stories, because others who have spoken previously had the courage to share their own experience. I pay particular tribute to my hon. Friend the Member for Washington and Gateshead South. I have certainly never forgotten her speech about Lucy, and she really has blazed a trail for others to follow.
I can honestly say that, in the last year, the most difficult meetings have been those with victims of the NHS. I think we should pause for a moment just to reflect on how outrageous that sentence is—victims of the national health service. They are people who, in their moments of greatest vulnerability, placed themselves and their lives and the lives of their unborn children in the hands of others, but who instead of finding themselves supported and cared for, found themselves victims. It is truly shocking.
I have heard dozens of stories, each unique, each told with heartbreaking clarity and each with a common theme: that what should have been a moment of joy became a terrifying ordeal. I have had complete strangers describe to me, a Government Minister, their experience of injuries endured in childbirth. Women have had to share with me, a total stranger, what it has done to their sex lives and what it has done to their continence. I have had fathers share with me for the first time their attempts at suicide, and the impact that their loss and grief has had on their mental health. We also heard from my hon. Friend the Member for Erewash (Adam Thompson) of the harm done to young people, in this case young Ryan, who was with us in the Gallery today. I have seen photographs of parents’ children. I have seen the ashes of their children in the tiniest boxes. I have seen more courage than I could ever imagine mustering if I had to walk a day in their shoes.
Each time they have met me—each time they have met anyone—they have had to relive the trauma inflicted on them by the state. Perhaps what is most shocking of all is that if there is another theme that ties these families together, it is the fact that they have had to battle time and again for truth, for justice, for answers, for accountability and for change, so that other families do not have to experience what they are going through.
I cannot thank enough the Members on both sides of the House who have placed on record not just the stories, but the names of the children we have lost, so that they can stand on the record there for all time, a stain on the history of our national health service, but also a galvanising call to action. I hope there is some small comfort for families who have been with us in the Chamber this evening to hear the debate, or who have watched online, to know that Parliament is listening, that we are learning, and that, crucially, we are acting.
Many Members have remarked on my personal responsibility and the responsibility that weighs heavily on my shoulders to get this right. We have been joined by some of the Nottingham families this evening. When I have met them, they have arranged themselves around a horseshoe table in date order, with those whose experience goes back furthest sat to my left, and those most recently sat to my right. I go back to Nottingham regularly and honestly dread the prospect of going to another meeting with another family arriving on my right-hand side at that end of the table with another story to tell, but one that has happened on my watch.
We know how serious these situations and challenges are. We have an implicit message from the system that tells women not to have a miscarriage at the weekend. We have women who are classed as having a normal birth still leaving traumatised and scarred. We still use terms such as “normal” to describe a particular type of birth for ideological reasons. All these things need to change.
We heard from my hon. Friends the Members for Clapham and Brixton Hill, for North West Leicestershire (Amanda Hack) and for Wolverhampton North East (Mrs Brackenridge) the shockingly wide race and class inequalities. We should not kid ourselves that these are statistical anomalies or just institutional failures, because I have heard time and again direct first-hand experiences of overt racism: black women told that it was assumed that that they would be “a strong black woman” and so would not need so much pain relief; and examples of Asian mothers described as divas. Perhaps most shockingly of all, taking a step back and looking at the overall picture, we have had the normalisation of deaths of women and babies. We have levels of loss and death in this country that are simply not tolerated in others. We have a shocking culture of cover-up and backside covering, as we have heard across the Chamber this evening.
Recognising that I cannot respond to every individual point that has been made in the debate, I will undertake to write to Members across the House with detailed answers to the questions they posed. I want to conclude by making this point, which is about trust. We are setting out the rapid investigation led by Baroness Amos because I need to act urgently on the systemic challenges. I want to acknowledge openly and publicly that not all families are with me on this; many have concerns, and they wonder whether this will be just another review that sits on the shelf. I want to conclude by assuring those families and this House of my personal commitment to ensuring that that is not the case, and not just through leading the taskforce that will implement the recommendations myself, but by giving a promise to this House and to those families, in the spirit set out by my hon. Friend the Member for Sherwood Forest, that grief must be the engine of change. The stories I have heard from those families at first hand will be the steel in my spine to deliver the change they need.
Andy MacNae
Thank you, Madam Deputy Speaker. I will speak relatively briefly. I would just like to thank everybody for their presence, honesty and passion today. This has been a moving, deeply powerful and deeply impactive debate. I particularly thank the Secretary of State, not just for being here, but for the passion, anger and urgency in his speech.
There are a million things I would like to talk about, but I will just reflect very briefly on the words of the hon. Member for Dorking and Horley (Chris Coghlan) about Billy and Billy’s parents and taking tragedy and turning that into positive change. If there is one idea that I think sums up this debate, it is the chance to take tragedy and turn it into positive change—an action that makes real difference. That is the task before us, and I thank everyone for supporting it.