Health and Social Care Committee
Wednesday 15th July 2026
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09:30
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09:31
Speaker 1
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Speaker 1
Well, thank you all for being with us today. Um, so Baroness Amos, if I might start, um, with you and the pulling together of this review, um, how easy did you find it to get the information you needed to do this incredibly comprehensive piece of work?What challenges did you face?And, um, where might you highlight some resistance in the system?Because I'm aware that some happened.
09:32
09:32
Speaker 4
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Speaker 4
Uh, good morning. Thank you. And, um, if I may, chair, just say three very quick things by way of introduction. Um, before answering your question. Um, first, I thank the committee for inviting us to give evidence this morning, uh, to thank the families who contributed to our investigation and repeated painful, distressing and traumatic experiences. And we'd like to give our condolences to those families who experienced bereavement. Also, to thank everyone who contributed to our review.
Uh, the second thing I would like to say, um, is that we did this review in ten months and the scale of it is unprecedented. Uh, when we started, I did not expect that we would have, uh, in that ten months, visited 22 hospitals across 12 NHS trusts had over one. 10,500 people respond to our call for evidence. 000 staff respond to our call for evidence we analysed 9500 pieces of evidence. We interviewed 40 national leaders, spoke to 19 MPs and five Appg sessions.
We had 15 evidence panels for stakeholder organisations, particularly around inequalities, because we were so concerned about what was happening, as well as doing a review of previous recommendations and international comparisons in terms of the challenges, I think I would say the scale of what we sought to do in a ten month period was unprecedented. Uh, we have not been able to reflect every single thing that we found in our report. And of course, that has led to criticisms from some communities that they do not feel that what they told us is reflected.
Uh, the second thing I would like to say, um, is that we did this review in ten months and the scale of it is unprecedented. Uh, when we started, I did not expect that we would have, uh, in that ten months, visited 22 hospitals across 12 NHS trusts had over one. 10,500 people respond to our call for evidence. 000 staff respond to our call for evidence we analysed 9500 pieces of evidence. We interviewed 40 national leaders, spoke to 19 MPs and five Appg sessions.
We had 15 evidence panels for stakeholder organisations, particularly around inequalities, because we were so concerned about what was happening, as well as doing a review of previous recommendations and international comparisons in terms of the challenges, I think I would say the scale of what we sought to do in a ten month period was unprecedented. Uh, we have not been able to reflect every single thing that we found in our report. And of course, that has led to criticisms from some communities that they do not feel that what they told us is reflected.
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09:33
Speaker 4
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Speaker 4
In the report. Thank you. We were very clear. Um, we have published 12 trust reports. They're a snapshot of where we were in a trust 2 or 3 days. They were not CQC type investigations. Uh, but reflecting back to the trust, what families told us and also what their own staff told us about their performance, uh, was. Uh, it was a. Challenge, but it was a very important thing to do.
I think breaking down what we had found into a set of recommendations that address the systemic challenges that face maternal and neonatal care, was very much one of the challenges because the previous investigations had all been case review and one NHS trust focused. Uh, this is important and different as against which maternity and neonatal care is judged. There is too much variation. Uh, there is way too much fragmentation in the system. And I think finally, the, the scale of the embedding of rape, uh, this is important and different, as well as our recognition that there is not one set of national standards against which maternity and neonatal care is judged.
There is too much variation. Uh, there is way too much fragmentation in the system. Uh, and I think finally, the, the scale of the embedding of racism and discrimination, as well as the issues around not listening to women and families and a lack of accountability in the system are all areas which I think are challenging. But if all of our recommendations and our recommendations interconnect, if all of those recommendations are implemented, will make a significant difference.
I think breaking down what we had found into a set of recommendations that address the systemic challenges that face maternal and neonatal care, was very much one of the challenges because the previous investigations had all been case review and one NHS trust focused. Uh, this is important and different as against which maternity and neonatal care is judged. There is too much variation. Uh, there is way too much fragmentation in the system. And I think finally, the, the scale of the embedding of rape, uh, this is important and different, as well as our recognition that there is not one set of national standards against which maternity and neonatal care is judged.
There is too much variation. Uh, there is way too much fragmentation in the system. Uh, and I think finally, the, the scale of the embedding of racism and discrimination, as well as the issues around not listening to women and families and a lack of accountability in the system are all areas which I think are challenging. But if all of our recommendations and our recommendations interconnect, if all of those recommendations are implemented, will make a significant difference.
09:35
Speaker 1
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Speaker 1
And we've seen I mean, we're speaking to Donna Ockenden in Panel two, but it's not the first time from, uh, her review echoed what others have heard. Um, which is executive teams in hospitals in trusts, ICB leadership's not always fully appreciating the scale of what was happening. Did you find that as well in your review?And, and were there some trusts where there was best practice and other trusts where they weren't?Would you be willing to share some of those leadership and accountability stories that have been clearly identified in yours and other reviews?
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Speaker 4
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Speaker 4
Uh, so just to go back to, to the generic point, um, in relation to, um, to trusts and what they're seeking to do, one of the things that we were very concerned about was the fact that there are parts of the country where the complexity in terms of demography is such that it is our view that those trusts need additional support, uh, areas of deprivation. Uh, very mixed communities. And the people who are working in the trust are also the people who are the service users of the trust.
So, uh, very major challenges there, uh, in addition to that, uh, the kind of layering of recommendations for local trusts to implement, there is no one national repository of recommendations and prioritisation of those recommendations.
So, uh, very major challenges there, uh, in addition to that, uh, the kind of layering of recommendations for local trusts to implement, there is no one national repository of recommendations and prioritisation of those recommendations.
09:37
09:37
Speaker 4
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Speaker 4
Yeah, but but this is not even about the task force. This is about how the system functions. Currently, no sense of, you know, what is the evidence base behind a recommendation which is being made?And where does that sit in terms of its priorities?So we saw 12 trusts. Um, we, uh, and. Within and between trusts, there is significant variation. So we saw both good poor and excellent practice within the same trust as well as between trusts.
So there is good practice everywhere. Uh, there is also, uh, elements of poor practice, almost everywhere. And there is not a, a way or a sense in which trust can learn from each other where there is good practice. So that is part of what we have fed back. A number of trusts have had feedback sessions with us. And part of what we have sought to do is to indicate, uh, to each other how they can help each other.
Um, in terms of.
So there is good practice everywhere. Uh, there is also, uh, elements of poor practice, almost everywhere. And there is not a, a way or a sense in which trust can learn from each other where there is good practice. So that is part of what we have fed back. A number of trusts have had feedback sessions with us. And part of what we have sought to do is to indicate, uh, to each other how they can help each other.
Um, in terms of.
09:38
09:39
Speaker 4
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Speaker 4
In terms of you, uh, we saw a, a large number of families. I think it's the trust where we saw the largest number of families, both in relation to, um, the John Radcliffe site, but also to their second site. We talked to a lot of staff. We found an extremely poor estate. I mean, we actually had a debate, um, as an investigation team as to whether or not it was the worst estate that we had seen. We determined that actually it wasn't, but it, um, it came pretty low down.
Uh, we found a leadership team that, uh, we felt did not understand the challenges that they faced, were not listening sufficiently to the voices of the women and families in their communities. We recently had a feedback session, um, with the leadership of that trust and actually were very impressed with the way that they have taken on board. Our findings. Um, have apologised to their community and are now making significant efforts to see how and what they can do to improve.
Uh, we found a leadership team that, uh, we felt did not understand the challenges that they faced, were not listening sufficiently to the voices of the women and families in their communities. We recently had a feedback session, um, with the leadership of that trust and actually were very impressed with the way that they have taken on board. Our findings. Um, have apologised to their community and are now making significant efforts to see how and what they can do to improve.
09:40
Speaker 1
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Speaker 1
So already there's, there's positives. I've spoken with them myself and it is interesting how they reacted in a very positive way to your challenge. So to the task force, and again, I must say I'm on the expert reference group, along with our vice chair, Paulette Hamilton, um, that are feeding into the task force on it, but we feed into it. Um, very briefly because I'm running out of time, we do want to dive into many of the other issues in your report, but what advice would you give the secretary of state who co-chairs this?Um, to make it actually work?What's the number one thing that you want to make sure is uppermost in their minds as they move forward with this task force?
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09:41
Speaker 4
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Speaker 4
Um, as I said previously, our recommendations interconnect their system focused, but we did take a families first approach as an investigation. So all of the work we did fell in, folded into our thinking about those recommendations. So the first thing I would say to the Secretary of State and to the task force is, please accept all of our recommendations, uh, because implementation of all of them will make a significant difference. Uh, they are long term. Um, we have set time frames.
There are some urgent actions now, and I'm pleased to see that what we have said on triage, for example, has already been accepted. What we have said on the maternity commissioner has already been accepted. But please don't do a pick and mix here. Um and if there were one other thing I would say to the task force and to the Secretary of State, listening to Women and racism and discrimination are often seen as these challenging cultural issues that it's very hard to address, that you do a little bit of training here and you do a little bit of training here.
It is safety critical. The outcomes are worse. If you take a safety critical approach, you embed these issues into how you think about developing your services, how you think about implementing your services, and the way that your staff conduct themselves as they carry out these services. So that safety critical principle is absolutely vital.
There are some urgent actions now, and I'm pleased to see that what we have said on triage, for example, has already been accepted. What we have said on the maternity commissioner has already been accepted. But please don't do a pick and mix here. Um and if there were one other thing I would say to the task force and to the Secretary of State, listening to Women and racism and discrimination are often seen as these challenging cultural issues that it's very hard to address, that you do a little bit of training here and you do a little bit of training here.
It is safety critical. The outcomes are worse. If you take a safety critical approach, you embed these issues into how you think about developing your services, how you think about implementing your services, and the way that your staff conduct themselves as they carry out these services. So that safety critical principle is absolutely vital.
09:42
09:42
Speaker 4
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Speaker 4
The biggest risk is that it all it there is insufficient monitoring that it all takes too long, that things fall off the end, that, uh, they are told that there are capacity and other issues that make this difficult. Uh, my personal view is that this is so important and critical for maternity and neonatal services going forward. How in today's world and looking forward, we still have the scale of harm and bereavement that we do. Uh, I find it extremely difficult to get my head around, I have to say, and it is the reason that I agreed to chair this investigation because I can't understand how England in 2026, with the resources we have at our disposal that we have not managed to deal with this.
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09:43
Speaker 5
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Speaker 5
Thank you. And thank you, Baroness Amos. Um, Gloucestershire Royal Hospital and the trust was included in your report. Um I should declare that I had a baby there a couple of years ago now. Um and so we were recently service users, um of that service. One of the key themes in your report, which aligns with all of the discussions I've had with women in Gloucester, is how often they feel dismissed and not listened to. And ahead of this session this morning, this morning, I've asked, um, women in my constituency to write in with their experiences so that I can share some of those and get your response.
One constituent told me that having been given a spinal block. She reported continued discomfort to her consultant, and in response, the male consultant tutted at her and said, it's not magic. Another constituent reported that after the premature birth and subsequent death of her son, she was told by a member of staff it's just one of those things you. Recommend that action is taken to listen to the voices of women like those in my constituency in Gloucester. But what practical steps. What.
What training do we need to give?What action do we need to take to make sure that staff listen to. Women are careful with their language and what should happen when women report being treated this way by healthcare professionals?
One constituent told me that having been given a spinal block. She reported continued discomfort to her consultant, and in response, the male consultant tutted at her and said, it's not magic. Another constituent reported that after the premature birth and subsequent death of her son, she was told by a member of staff it's just one of those things you. Recommend that action is taken to listen to the voices of women like those in my constituency in Gloucester. But what practical steps. What.
What training do we need to give?What action do we need to take to make sure that staff listen to. Women are careful with their language and what should happen when women report being treated this way by healthcare professionals?
09:45
Speaker 4
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Speaker 4
So if I could start and then I'll hand over to Professor Sanders, if I may, um, we found medical misogyny. Um, across the system and the recent women's health strategy spoke about this, um, as well, which is why listening to women, uh, is something that has not just come out of our findings, but has come out, um, from findings across the piece. And in terms of what do we need to do?That is why we say that the first step has got to be embedding listening to women as a safety critical issue, because it means that trust executives and the boards of trusts treat it very differently.
The data that they collect, how and when they talk about it, how they look for trends, how they measure and monitor. It's very different. It's very different. If you have an issue as a safety critical issue embedded in your performance, as opposed to if you just have it as an add on in terms of the specifics that you just asked about, I'll hand over to Professor Sanders.
The data that they collect, how and when they talk about it, how they look for trends, how they measure and monitor. It's very different. It's very different. If you have an issue as a safety critical issue embedded in your performance, as opposed to if you just have it as an add on in terms of the specifics that you just asked about, I'll hand over to Professor Sanders.
09:45
Speaker 3
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Speaker 3
Thank you. And yes, firstly, to acknowledge we too heard far too many examples, experiences of completely unacceptable language attitudes being shown to women and their families. Um, we and addressing that culture that says this is not acceptable. It is not acceptable to dismiss the concerns of women and families. Um will take big change. It will take time, but we have to set those standards. Um, and that's through not only through training, but through through strong leadership.
And one of our recommendations around we need to improve that leadership right through from board level through to the senior midwives and obstetricians through to every single encounter, um, in order to, to change that for, to have strong leaders that are prepared to say that behaviour is not acceptable. You need to listen to women, you need to respond to them. This is how this is acceptable language. This is language we do not tolerate in this organisation. There are practical challenges in terms of the capacity that lots of units.
We saw many units that were working at very high capacity levels, and that in itself produces an environment in which staff are stretched. This is not to justify the way that they behave, but when you're tired and you haven't had a break and you're working long shifts, inevitably you become less nice to people. And that's that needs to be addressed within within workforce measures.
And one of our recommendations around we need to improve that leadership right through from board level through to the senior midwives and obstetricians through to every single encounter, um, in order to, to change that for, to have strong leaders that are prepared to say that behaviour is not acceptable. You need to listen to women, you need to respond to them. This is how this is acceptable language. This is language we do not tolerate in this organisation. There are practical challenges in terms of the capacity that lots of units.
We saw many units that were working at very high capacity levels, and that in itself produces an environment in which staff are stretched. This is not to justify the way that they behave, but when you're tired and you haven't had a break and you're working long shifts, inevitably you become less nice to people. And that's that needs to be addressed within within workforce measures.
09:47
Speaker 5
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Speaker 5
I think, you know, from a personal perspective, I had a fantastic experience. And the midwives that looked after me and my wife or my wife and my my little boy and our family were fantastic. This isn't, you know, to target individuals at all. And the questions I'm asking today, because lots of them were incredibly hard and trying to do the right thing. But the system is obviously not working and letting them down. And alongside. And I hear what you're saying about kind of the capacity challenges.
But another constituent wrote in to say that after birth, her daughter was transferred to the NICU where she the mother was transferred to a maternity unit without her husband or her daughter, and then was put on a full bay with other new mothers, with their new babies. And she was understandably distraught by the crying of the new babies while she was, um, taken, you know, taken, you know, had her baby taken away to the NICU. And when she asked to be moved. She was told by staff that she should go and buy some earplugs from Asda.
And it leads me to ask, clearly there's an issue around the attitude, but also what practical changes can we make?Um, so that all mothers can have that emotional support that they need in these intensely vulnerable moments?
But another constituent wrote in to say that after birth, her daughter was transferred to the NICU where she the mother was transferred to a maternity unit without her husband or her daughter, and then was put on a full bay with other new mothers, with their new babies. And she was understandably distraught by the crying of the new babies while she was, um, taken, you know, taken, you know, had her baby taken away to the NICU. And when she asked to be moved. She was told by staff that she should go and buy some earplugs from Asda.
And it leads me to ask, clearly there's an issue around the attitude, but also what practical changes can we make?Um, so that all mothers can have that emotional support that they need in these intensely vulnerable moments?
09:48
Speaker 4
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Speaker 4
So if I may, if I may start, um, so we are very clear in our report that, uh, there is. Psychological trauma that women experience, which needs to be addressed as a matter of urgency. And that this is distinct from bereavement care. We also say in our report, um, we make a recommendation that the estates, I mean, a lot of the estates that we saw were not fit for purpose. And what you describe is something that we came across time and time again, and we make a recommendation in the report that there should be 12, five and ten year plans to improve the estates of maternity and neonatal care across the country.
And, um, obviously, there will be financial implications, um, linked to that, but it is urgent to actually do the reviews of the estates and to have those plans and then think about, uh, the costs attached. Um, we recommend that, uh, in all the training, um, that, uh, trauma informed training, compassionate care, uh, is integrated into the training that every single member of staff has. Um, there are midwives and other staff who are specialists in certain kinds of care. We don't think that that's enough.
We think that everybody needs to be trained because everybody needs to be able to speak, uh, to women, birthing people and families, uh, with compassion, but with confidence that they are being compassionate. Because one of the concerns that many have is that they don't know what to say, and they don't know how to say it. Uh, so this, so it's both a cultural issue, but it's also a structural factor.
And, um, obviously, there will be financial implications, um, linked to that, but it is urgent to actually do the reviews of the estates and to have those plans and then think about, uh, the costs attached. Um, we recommend that, uh, in all the training, um, that, uh, trauma informed training, compassionate care, uh, is integrated into the training that every single member of staff has. Um, there are midwives and other staff who are specialists in certain kinds of care. We don't think that that's enough.
We think that everybody needs to be trained because everybody needs to be able to speak, uh, to women, birthing people and families, uh, with compassion, but with confidence that they are being compassionate. Because one of the concerns that many have is that they don't know what to say, and they don't know how to say it. Uh, so this, so it's both a cultural issue, but it's also a structural factor.
09:50
Speaker 5
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Speaker 5
Final question, if I may, chair, um, your report touches upon the poor availability of professional interpreters. Um, which makes it harder for families to understand the care they're receiving and the informed consent. And this is particularly important in Gloucester. It's a diverse city. We've got many people in there whom English is their second language. And sadly, um, the lack of interpretation services led to the deaths of mothers in my constituency. Can you elaborate on what that looks like?I think in the report you touched upon community based approaches and how improving women's ability to engage with maternity services, how could those be replicated nationally?
09:51
Speaker 4
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Speaker 4
Um. Thank you again and again. Part of this is safety critical because the outcomes are worse, but it is also about how trust not only engage with the families, it's how trust engage with the communities and the organisations that represent those communities. Uh, we heard about terrible examples where family members were called upon to interpret or staff members were called upon to interpret. There are some trusts that are looking at different kinds of models, some of which involve interpretation. For example, on line, uh, we saw 1 or 2 trusts which have developed, um, robust community partnerships to assist with this.
So there are some very good examples out there that can be shared. And this is one of the areas where I think it's important that it trusts don't keep their good practice to themselves. But there is a way which is found to share this nationally.
So there are some very good examples out there that can be shared. And this is one of the areas where I think it's important that it trusts don't keep their good practice to themselves. But there is a way which is found to share this nationally.
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Speaker 6
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Speaker 6
Um, your review says that the CQC lacks credibility. Um and looking at some of the evidence, it's not a surprise. Why?Um, looking specifically at the Nottingham Review, um, the Nottingham uh there were first kind of issues identified in 2007 in reporting and serious incident regulatory inspections, but then took 13 years for the CQC to identify serious and persistent concerns and then a further five years for charges to be brought by the CQC. Why is it taking the CQC so long to act?Seemingly in these cases?
09:53
Speaker 4
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Speaker 4
Well, what we found looking at the CQC, and I do have to say to the committee that this was raised at the outset by the issue of regulation. The CQC was raised by many, many families at the outset, and they actually wanted us to conduct a more in-depth review of the CQC, which, um, we were unable to do. But I did write to the Secretary of State at that time, uh, making families views clear. What we found significant regional variation in the way that the CQC operates, a lack of clear standards, standards changing regionally.
And indeed, when we talk to some trusts that even in the midst of an investigation, what they were being judged against changed as they were being investigated. Insufficient expertise within the CQC to judge what was happening in.
And indeed, when we talk to some trusts that even in the midst of an investigation, what they were being judged against changed as they were being investigated. Insufficient expertise within the CQC to judge what was happening in.
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Speaker 4
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Speaker 4
Um, yes, absolutely. Our view is that you need to have um, expertise within the CQC to handle this. Um there is one trust, for example, where the CQC identified seven significant safety failures, um including women leaving triage without assessment. And they assessed that trust as good um which we found.
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09:55
Speaker 4
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Speaker 4
It absolutely needs to change because this is the lever that trust boards use. To identify what is critical and what needs changing in their trust. And if you can't trust the regulator and can't trust what the regulator is telling you, then you are not going to end up in with a, a service that has better quality and is safer for women and families.
09:55
Speaker 6
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Speaker 6
Thank you. And it's very worrying. You think it's possible to reform and improve the CQC, or is it a fundamental issue with with. A general regulating approach, having kind of. Also this responsibility to kind of check for safety to come in when there's perhaps more serious issues. Is it possible to do both?
09:55
Speaker 4
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Speaker 4
I think it is possible to reform the CQC. Um they're going through uh leadership changes at the moment. They had a review um by. Penny dash which identified, uh a number of issues that the CQC need to address. Um, our strong view as an investigation is that you need within the CQC to have a specialist function, which does the reviews of maternity and neonatal care with the expertise required, uh, with the investigators having the expertise required.
09:56
Speaker 6
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Speaker 6
These are unique issues of maternity and neonatal services. So you want your standalone inspection unit. Is there likely to be other safety?I mean, we've had the Bristol baby scandal at the heart. Of pediatric cardiology and very serious historic cases before. Not to say that's necessarily continuing, but there have been other areas of care where there's been serious and persistent failures of safety. So do you think it is unique to maternity and neonatal, or do you think there's likely to be broader improvements to see CQC?
09:57
Speaker 4
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Speaker 4
We had a discussion about this as an investigation team. We do think that there are some specific areas of maternity and neonatal care that are unique. Um, we also recognise that the recommendations that we make, not just in relation to the CQC, but across the piece, will have the impact of improving, uh, the health service more generally. But I can see Doctor Ochichi wanting to come in.
09:57
Speaker 2
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Speaker 2
Thank you. Um, I think that's a very important question. Now, ultimately, when assessors are coming in to assess any service, um the parameters with which they are assessing the service, often having, understanding, having previous experience, having worked in that system allows that critical eye and that understanding as to what is causing that, what's causing those pressures. Being able to provide that standardized assessment. And so I think particularly in the area of maternity and neonatal care, maternity care, having assessors that have the understanding and the expertise of maternity and neonatal care is imperative.
09:57
Speaker 6
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Speaker 6
Thank you. Just lastly, turning to one other issue on this theme actually about specialism, your review was tasked at looking at neonatal and maternity services. There's been some criticism that it hasn't looked at neonatal care services specifically, but only generally in the context of maternity. And they are specific disciplines. I think bliss, for instance, neonatal care charity, has charged that some of the recommendations are perhaps too influenced by maternity thinking. Do you recognise that concern?What's your response to it?
09:58
Speaker 3
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Speaker 3
If I may come in, I think we of course we we appreciate their concern. I would like to reassure them that absolutely. The neonatal voice was very strong in this investigation. Um, and that was through a similar number of neonatal consultants involved as expert advisors. But right through at every single point we heard from many parents who had had babies on, the neonatal units with the public, um, survey had many responses from, from parents that had experienced neonatal care. There was certainly no diminishing of the importance of neonatal care.
And that interface with maternity. But what we did find often was actually the the neonatal services were not often coming under the same criticism that maternity services were. And therefore it's not. The recommendations, if they're more reflective of maternity services, that's that's reflective of the evidence that we gathered and the evidence that we heard from parents and from staff. Um, and certainly the staff survey. Reflected quite strongly that the neonatal services, um, in terms of the time pressures and in terms of their, the resources that they have are not as great as, as maternity services are experiencing.
That's not to say that they don't have their pressures, they don't have their challenges. Um, but they're not experiencing them at the same level as the rest of maternity services.
And that interface with maternity. But what we did find often was actually the the neonatal services were not often coming under the same criticism that maternity services were. And therefore it's not. The recommendations, if they're more reflective of maternity services, that's that's reflective of the evidence that we gathered and the evidence that we heard from parents and from staff. Um, and certainly the staff survey. Reflected quite strongly that the neonatal services, um, in terms of the time pressures and in terms of their, the resources that they have are not as great as, as maternity services are experiencing.
That's not to say that they don't have their pressures, they don't have their challenges. Um, but they're not experiencing them at the same level as the rest of maternity services.
10:00
10:00
Speaker 7
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Speaker 7
Yes, thank you. Thank you, chair, and thank you all so much for coming. Baroness Amos, you recommended the appointment of a National Maternity and neonatal commissioner to, as you put it, drive change. Um, what immediate changes do you think this will make to the experience of women and birthing people?And what resources do you think the commission will need to have and backing from the government?So they're not just sort of shunted off into a siding.
10:01
Speaker 4
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Speaker 4
Uh, well, it won't be immediate, um, because our recommendation is that this is on a statutory footing, which would mean what we've recommended is that, uh, an amendment is made in the current health bill to, to, uh, make sure. That this happens. So even with that, um, that would not happen until the end of the year, then you would have to appoint someone. The difference that it would make. Um, it's about oversight and it's about driving change. So, um, independent.
Of government reporting annually to parliament reporting annually to families reporting, um, twice a year to this committee so that it is possible to see, uh, what is happening in terms of implementation, um, where the gaps are, where the challenges are, what is needed to continue to drive that, that change. It's an oversight role. Uh, we looked at the models of, for example, the victims commissioner, the children's commissioner. We did not make any kind of recommendation as to what the support should look like. I think this is something for the task force.
Uh, and the department to think about.
Of government reporting annually to parliament reporting annually to families reporting, um, twice a year to this committee so that it is possible to see, uh, what is happening in terms of implementation, um, where the gaps are, where the challenges are, what is needed to continue to drive that, that change. It's an oversight role. Uh, we looked at the models of, for example, the victims commissioner, the children's commissioner. We did not make any kind of recommendation as to what the support should look like. I think this is something for the task force.
Uh, and the department to think about.
10:02
10:02
Speaker 4
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Speaker 4
Yes. The support that the commissioner should have. Yes. I thought that was the second part of your question. Um, so we did not uh, so whilst we looked at the models, we did not have a recommendation as to, you know, how many support staff there should, there should be anything like that. We were more concerned about the effectiveness of this role, working with the leadership across the NHS, working with the taskforce, but having this independent oversight role so that the implementation, as it were, doesn't slip back.
10:03
Speaker 4
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Speaker 4
Uh, so the powers would partly be in terms of their statutory reporting to Parliament and to this committee. So, uh, the system, as it were, has to give the data and the information and everything else to enable the commissioner to report. But it is also a role that would work with the leadership in the NHS.
10:03
10:03
Speaker 4
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Speaker 4
I would anticipate that the commissioner would do that. Yes. Um, if this was something that was absolutely vital in terms of as we have said, it is, uh, because we think it's important to drive the system. So data is crucial to driving the system. The commissioner would have the responsibility to say to the system, this data has got to be produced. How are you going to do it?
10:04
10:04
10:04
Speaker 7
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Speaker 7
At the end of the year. Um, the, the actual year. Um so, so then we would have to recruit. And so we're talking a few months after that. So when the minister talked about Secretary of State talked about a plan, a six month plan to implement your report, um, sorry, the six month plan to implement your report, the person who is going to become the commissioner would have no say in shaping that plan, and they would actually come in several months.
If the plan is going to be produced by Christmas. They'd come in several months after the plan had been produced to implement it. So there's going to be a hiatus, is that right?
If the plan is going to be produced by Christmas. They'd come in several months after the plan had been produced to implement it. So there's going to be a hiatus, is that right?
10:05
Speaker 4
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Speaker 4
So I think what the Secretary of State was talking about is the secretary of State is chairing the task force. Um, and the task force was the role of the task force was always to take the recommendations from our review, as well as from other reviews, including the Nottingham review. And by the end of the year, turn those recommendations into an action plan. So. Uh, six months from now, uh, an action plan, uh, the, as you say, the commissioner would not have a role in shaping that action plan, but that was always the role of the task force.
We recommend that the commissioner co-chairs the task force with the Secretary of State, because we see that that independent oversight as being important, both in terms of independent of government as well as independent of the department as well. So, yes, the commissioner would come in and there would be an action plan, but action plans are evolving documents. So I would anticipate that over time, the commissioner would have a role in influencing that action plan.
We recommend that the commissioner co-chairs the task force with the Secretary of State, because we see that that independent oversight as being important, both in terms of independent of government as well as independent of the department as well. So, yes, the commissioner would come in and there would be an action plan, but action plans are evolving documents. So I would anticipate that over time, the commissioner would have a role in influencing that action plan.
10:06
Speaker 7
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Speaker 7
Finally, you recommended that a modern service framework for maternity and neonatal services be set up within 12 months. To be honest, as a committee, we are unsure about how these frameworks will drive change. Um, are you confident that it's going to be an effective mechanism for improving maternity and neonatal services?If you are?Why?
10:06
Speaker 4
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Speaker 4
Because these are these are part of, um, as the committee knows, part of the ten year plan. Um, and this is the thing that will set the national standards for maternal and neonatal care. So that's what the, it's an odd kind of name, I think modern service framework. But part of what we sought to do as an investigation was make sure that we weren't reinventing the wheel, that we are working as much as we can with what is already happening that we think is good and positive.
Uh, so that you're not adding recommendation on recommendation, as we've seen, uh, previously, you will have seen that we did a review of the over 700 recommendations that already exist in maternal and neonatal care. So that's the thing that would drive the setting of the standards against which, uh. We will then monitor what is happening in maternity and neonatal.
Uh, so that you're not adding recommendation on recommendation, as we've seen, uh, previously, you will have seen that we did a review of the over 700 recommendations that already exist in maternal and neonatal care. So that's the thing that would drive the setting of the standards against which, uh. We will then monitor what is happening in maternity and neonatal.
10:07
10:07
Speaker 4
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Speaker 4
Well, then you have the standards against which you are monitoring. So part of the commissioner's role in terms of oversight is driving, helping the system to drive the implementation and identifying where there is, for example, backsliding or, uh. Where additional resources are needed or where there are gaps in implementation. So it's about driving, uh, implementation forward.
10:07
Speaker 1
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Speaker 1
Thank you, chair. And I just want to pick up on something that my colleague asked earlier around the scale of issue, um, and how it relates to the wider hospital system. So do you think that the maternity issues you've identified, by and large are reflect. In the hospitals in which they sit and I suppose to look at it another way, is it possible to find an exemplary maternity unit in a failing hospital?
10:08
10:08
Speaker 2
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Speaker 2
That's a brilliant question. Um, I personally work in an outstanding unit, um, within a trust that some of its services are outstanding. Some of its services are good, some of its services have challenges. We do know that when we talk about leadership, we also we mean the leadership at the top. So that is that trust level. And what we found when we visited across the 12 units is that where there was poor leadership, we often found trusts, maternity services that were struggling.
And conversely, where we had strong leadership and leadership that understood and had buy in into maternity services, we had strong maternity services. From my point of view, it's always interesting to look at services that are outstanding and understand why they are outstanding. Are they outstanding because the maternity system nationally allows that, or are they outstanding in spite of. And what we found was that there was this inconsistency in care. That is maternity care that's delivered across the country. So that's means that outstanding services occur in spite of the system.
So therefore, our report and our recommendations is to standardise high quality maternity and neonatal care for everybody every single time. And that would mean as part of that, to strengthen poor leadership all the way. So from the service delivery leaders, all the way to trust leadership such that we can then see improvement in our maternity services.
And conversely, where we had strong leadership and leadership that understood and had buy in into maternity services, we had strong maternity services. From my point of view, it's always interesting to look at services that are outstanding and understand why they are outstanding. Are they outstanding because the maternity system nationally allows that, or are they outstanding in spite of. And what we found was that there was this inconsistency in care. That is maternity care that's delivered across the country. So that's means that outstanding services occur in spite of the system.
So therefore, our report and our recommendations is to standardise high quality maternity and neonatal care for everybody every single time. And that would mean as part of that, to strengthen poor leadership all the way. So from the service delivery leaders, all the way to trust leadership such that we can then see improvement in our maternity services.
10:09
10:10
Speaker 4
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Speaker 4
So I'll just add one thing to that really quickly, because one of the things that we say in our report is that you need a national framework that helps trust to implement, and we haven't got that at the moment. So if you're a trust and you haven't had an investigation, you get handed a whole set of recommendations. Uh, they are not necessarily shared across, they're not necessarily shared nationally. And you don't necessarily get support to help you to implement. So that national repository is also important.
10:10
Speaker 1
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Speaker 1
So just following on a bit from that in your review, Baroness Amos, are there any areas that you would have liked to have covered in greater detail that you weren't able to?You said you saw a lot of things in a very short space of time. Are there any areas where you think, actually, I would have liked to have looked at that in more detail.
10:10
Speaker 4
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Speaker 4
There are areas where I think that, um there is. Disappointment that we were not able to go into those areas in more detail. So for example, there were a number of campaigning groups around, uh, specialized medical conditions that we were not able to go into in detail. The whole area of maternal mental health. Is an area that needs urgent attention. And we have recommended to the task force that they need to look at this, um, and wider inequalities.
I mean, our report talks about racism and equality. We are very strong, I think on the issues around racism and discrimination. We talked to a representatives of a lot of organisations including um refugee organisations, Roma and Traveller, Muslim and Jewish, uh, communities, LGBT. Q plus, there is so much in the area of inequality that needs to be addressed. And this urgently needs to be tackled and linked to that deprivation more generally. Um, and again, in our report, we talk about the importance of linking up what is happening in maternal and neonatal care with what is happening in public health and what happens, you know, even before, um, a woman, uh, a birthing person becomes pregnant.
We were not able to go into the level of detail that we would have, would have liked to. But, you know, all of these have huge, uh, impact. On what is happening in maternal and neonatal care.
I mean, our report talks about racism and equality. We are very strong, I think on the issues around racism and discrimination. We talked to a representatives of a lot of organisations including um refugee organisations, Roma and Traveller, Muslim and Jewish, uh, communities, LGBT. Q plus, there is so much in the area of inequality that needs to be addressed. And this urgently needs to be tackled and linked to that deprivation more generally. Um, and again, in our report, we talk about the importance of linking up what is happening in maternal and neonatal care with what is happening in public health and what happens, you know, even before, um, a woman, uh, a birthing person becomes pregnant.
We were not able to go into the level of detail that we would have, would have liked to. But, you know, all of these have huge, uh, impact. On what is happening in maternal and neonatal care.
10:12
10:12
Speaker 4
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Speaker 4
The reaction has been mixed. Um, we anticipated that, um, when we started, for example, there were a group of families who spoke to me right at the beginning and said, um, we don't think that your report is going to deliver anything that we are looking for, because what we want is a statutory public inquiry. And they were very open and honest about that, uh, from the outset, uh, for example, um, there are campaigning and advocacy organizations that hoped that we would go into more detail on some of the issues that they are concerned about.
Uh, and we were not able to do that. Uh, there has been criticism of the report, um, with respect to what we said on normal birth ideology, for example, where, um, we did not want to dismiss the concerns of families who shared personal experiences of the findings from previous investigations. Um, but where from our investigation, we were not able to find evidence of a national prevalence of normal birth ideology. We didn't say that it didn't exist. Um, but we were not able to find the evidence of that despite, uh, a specific question in the call for evidence, despite all the interviews we did, uh, both with people in the workforce and also with families, I know that was, um, a criticism.
There's been criticism from harmed and bereaved families that despite the fact that we wanted to take a families first approach and wanted to be trauma informed that there is not enough in our report that speaks to that, um, experience. Um, and there's been quite a lot of criticism of that too.
Uh, and we were not able to do that. Uh, there has been criticism of the report, um, with respect to what we said on normal birth ideology, for example, where, um, we did not want to dismiss the concerns of families who shared personal experiences of the findings from previous investigations. Um, but where from our investigation, we were not able to find evidence of a national prevalence of normal birth ideology. We didn't say that it didn't exist. Um, but we were not able to find the evidence of that despite, uh, a specific question in the call for evidence, despite all the interviews we did, uh, both with people in the workforce and also with families, I know that was, um, a criticism.
There's been criticism from harmed and bereaved families that despite the fact that we wanted to take a families first approach and wanted to be trauma informed that there is not enough in our report that speaks to that, um, experience. Um, and there's been quite a lot of criticism of that too.
10:14
Speaker 1
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Speaker 1
And you sort of talked a little bit about your response to some of that criticism. Do you accept any of the criticism, and have you had time to reflect on, you know, no review is perfect, and if you had time to reflect on some of that criticism and how, you know, you perhaps would think slightly differently based on the response.
10:14
Speaker 4
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Speaker 4
Yes, we have, um, reflected on that criticism. I think it is absolutely fair to say that, uh, we have not recommended, um, a statutory public inquiry. Um, the view of the investigation from the outset has been that that's for the Secretary of State and for the government. It was not for us to determine, I think, within the context of our terms of reference and what we were able to look at in terms of normal birth ideology, I think that what we have said in our report reflects the evidence that, uh, we saw and heard, um, it's a nuanced position.
And I absolutely accept that. And I totally, um, understand that if, uh, if this has been your experience, the fact that we as an investigation team were not able to go further than we did, um, would have been a significant, uh, disappointment.
And I absolutely accept that. And I totally, um, understand that if, uh, if this has been your experience, the fact that we as an investigation team were not able to go further than we did, um, would have been a significant, uh, disappointment.
10:15
10:15
Speaker 4
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Speaker 4
So I have a personal view. I do not speak for, um, the investigation, uh, the families that have spoken to me have specifically talked about, for example, issues around accountability, uh, which I think are a report, if implemented, will help to address, um, have talked about the importance of individuals being compelled to give evidence. Uh, I think that some of that will be addressed through the new Hillsborough law, for example. So, um, I do not, but um, it's my personal view and I have not been through the traumatic and difficult experiences that those families have.
So in many ways, my view doesn't really count.
So in many ways, my view doesn't really count.
10:16
Speaker 1
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Speaker 1
And finally, I just want to ask, um, around the interplay, the overlap, the tension between your review and, um, the reviews that Donna Ockenden is undertaking. Um, and obviously we will hear from Miss Ockenden next, but I represent a constituency in Sussex. Um, and there will be a Ockenden review in Sussex. Um and I speak to University Hospital Sussex very regularly and obviously they have now had the your review um they've got over 100 recommendations both from your review and from looking at the Nottingham report.
Um do you think that they're. Well actually what do you think, do you think that these reviews are complimentary. Do you think that trusts like myself, you know in Sussex where we have an awful lot of pressure, there's an awful lot of other stuff going on, having an over 100 recommendations from both of these reports. Um do you think that that in and of itself could be problematic or that actually these recommendations are complementary and will allow trusts like Sussex, um one for the Sussex families to get the review that they've requested, but also to move forward with the maternity units where the staff are clearly working very hard.
How do you feel about both those reviews?
Um do you think that they're. Well actually what do you think, do you think that these reviews are complimentary. Do you think that trusts like myself, you know in Sussex where we have an awful lot of pressure, there's an awful lot of other stuff going on, having an over 100 recommendations from both of these reports. Um do you think that that in and of itself could be problematic or that actually these recommendations are complementary and will allow trusts like Sussex, um one for the Sussex families to get the review that they've requested, but also to move forward with the maternity units where the staff are clearly working very hard.
How do you feel about both those reviews?
10:17
Speaker 4
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Speaker 4
I think there's a huge amount of overlap in terms of the issues identified by the different reviews. In fact, one of the things that many people have said to us is that you haven't said anything different. I don't actually accept that, because I do think the points we make around safety, critical issues and so on, the national scope of what we did, looking at systems, um, is very different to case reviews in individual trusts. But there is a huge amount of commonality in terms of what all of those reviews have found in our review of previous recommendations.
And we, we very much did not want to add lots and lots and lots of recommendations on top of that. One of the things that we have said is that, you know, these these recommendations need to be looked at nationally, and they need to be prioritised, uh, because you know what you have, you can't have seven recommendations going 700 recommendations, going to trusts and trusts, not knowing, you know, what is more important than that?Where, where are the resources to do this?So there has to be national oversight of this.
And I hope that what comes out of the task force in December, um, in terms of the action plan, will have a degree of prioritization, uh, in that. Thank you.
And we, we very much did not want to add lots and lots and lots of recommendations on top of that. One of the things that we have said is that, you know, these these recommendations need to be looked at nationally, and they need to be prioritised, uh, because you know what you have, you can't have seven recommendations going 700 recommendations, going to trusts and trusts, not knowing, you know, what is more important than that?Where, where are the resources to do this?So there has to be national oversight of this.
And I hope that what comes out of the task force in December, um, in terms of the action plan, will have a degree of prioritization, uh, in that. Thank you.
10:19
Speaker 8
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Speaker 8
Thank you, Paula Hamilton. Good morning. Good morning Baroness, Amos and the other members of the panel. What what I'd like to do is start by just pressing in a little further about this. Not normal birth ideology. I think Becky covered the first bit quite well. So the the little bit I'm going to cover today, it's about what Bob um, I forgot his name. Bill Kirkup doctor Bill Kirkup, the fact that he stood down from his role as an expert advisor and he disagreed with the principals over the findings, even went as far as to say on BBC news that you were listening to the wrong people.
And I have to say that Miss Ockenden, um, Miss Ockenden told The Standard that women were being denied caesarean sections and with tragic outcomes. And it's a national issue. So what I'd like to ask you, could you tell us a little bit more about this?Because when we did our review, we started to hear things like that. But it hasn't come out in your report. So I'll hand over to you.
And I have to say that Miss Ockenden, um, Miss Ockenden told The Standard that women were being denied caesarean sections and with tragic outcomes. And it's a national issue. So what I'd like to ask you, could you tell us a little bit more about this?Because when we did our review, we started to hear things like that. But it hasn't come out in your report. So I'll hand over to you.
10:20
Speaker 4
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Speaker 4
Um thank you. So, um, I do think it's important for the committee to, um. Understand that um, whilst Bill Kirkup was one of the expert advisors on our panel. He did not participate in any of the panels that we did with families in any of the trusts. So he did not hear the evidence that we heard, um, from those families. Um, and as I said, um. What we were unable, in our evidence to find a national prevalence of a normal birth ideology.
We did find other things, um, in terms of a challenge, for example, with escalation when things weren't going right. But perhaps, Professor Sanders, you could say a bit more about that.
We did find other things, um, in terms of a challenge, for example, with escalation when things weren't going right. But perhaps, Professor Sanders, you could say a bit more about that.
10:21
Speaker 3
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Speaker 3
Yes. Thank you. So, absolutely. The first thing to say is, yes, we heard from women and families who did not receive medical interventions when they were clearly warranted. And and we and to acknowledge the harm, the psychological and physical harm and trauma that that has caused. But I think what we didn't hear was that was driven by ideology. It is well known in maternity services that there's a whole chain of events that leads to intervention.
So it's firstly recognition that you've got a problem, escalation to the right people and then the right interventions and that whole chain. If that breaks down at any point, it means the woman doesn't receive the care that she should do. And we certainly heard examples of that. But you need to what we need to explore further and what perhaps we're not exploring enough is why those issues are happening. So we certainly heard issues of staff, pressures of capacity when midwives were very aware that women needed reviews, particularly in triage, for example, and medical staff either weren't immediately available or weren't going to be available for quite some time.
So there are delays in treatments. We also are aware of the lack of um, senior staff that are often present in our units. Out of hours. We make a recommendation around a complete review of workforce planning and a new workforce planning tool, which.
So it's firstly recognition that you've got a problem, escalation to the right people and then the right interventions and that whole chain. If that breaks down at any point, it means the woman doesn't receive the care that she should do. And we certainly heard examples of that. But you need to what we need to explore further and what perhaps we're not exploring enough is why those issues are happening. So we certainly heard issues of staff, pressures of capacity when midwives were very aware that women needed reviews, particularly in triage, for example, and medical staff either weren't immediately available or weren't going to be available for quite some time.
So there are delays in treatments. We also are aware of the lack of um, senior staff that are often present in our units. Out of hours. We make a recommendation around a complete review of workforce planning and a new workforce planning tool, which.
10:23
10:23
Speaker 3
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Speaker 3
So we were very conscious when we went out and gathered evidence that clearly that this is an issue that that we were going to be challenged and asked about from the evidence that we gathered, and that was from the site visits, from talking to many staff, from the staff survey and from our public responses and seeing the services, we did not see evidence of women being deprived. Medical interventions due to an ideology, and the staff were very clear on that, that this is not happening out there. Um, and I think.
Our report needed to reflect the evidence that we gathered. And I believe that we we have done that with integrity and with honesty. It is not our position to put in the report something which we did not find.
Our report needed to reflect the evidence that we gathered. And I believe that we we have done that with integrity and with honesty. It is not our position to put in the report something which we did not find.
10:24
Speaker 4
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Speaker 4
Can I add one thing, other thing which is that, um women and families also told us the opposite, which is that um they were being encouraged down the route of medical intervention intervention, when actually what they wanted was a vaginal birth. Uh, so, um, and so just to really reinforce the point that's been made by Professor Saunders, um, it was our view as an investigation that it was not in the interests of women and families to make claims in our report that we could not substantiate.
10:24
10:24
Speaker 2
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Speaker 2
One one final point that ultimately the key in all of this is about women being listened to. Um, and it's important that, I mean, these discussions and debates is important, but we must always remember that it's the women at the centre. And so whether it's a woman that wants to have a vaginal birth, we must support that. And whether it's a woman that obviously wants to have a medicalized birth, the system needs to support that. And what we found, what the issues were.
10:25
Speaker 8
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Speaker 8
I disagree with you slightly. I'm a nurse by trade. My background is health. Sometimes I may want something, but it may not be the best outcome for me. And if I'm carrying a baby. So sometimes I may be determined. That's the direction I want to go in, but it may not be the best direction. And this is why we we absolutely support patient choice, but. You also have to we are the medical professionals and sometimes it may not work for them.
10:26
Speaker 2
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Speaker 2
Of course. And as an obstetrician, the final part of that sentence was to say, with the safety of the mother and the baby at the core. And so it's about the system and the mother being able to have that conversation and to support that journey. And of course, part of what we found, this is where the listening has been failing, because as obstetricians, as midwives, if we find that there is a deviation away from that path, then we must be able to have that conversation in a way that is trauma informed, is sensitive, has that empathy, and the capacity within the system is there so that we can maintain that safety.
10:26
Speaker 8
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Speaker 8
But I I'm going to stop you there, and I'm going to move on to another question. But could I also say sometimes the. Biggest issue we found from our report, people were not being listened to. And with this, um, birth ideology that the panelists talked about, if someone feels they've not been listened to and that midwife or doctor, um, obstetrician has an idea of a direction of travel, does the panel feel that sometimes if that obstetrician and that midwife, their idea is around the birth ideology, that what they then do is they don't necessarily say anything, but that's the direction they take.
The the mother in. And, and sometimes it leads to the conclusions that were found in places like Nottingham, Malcolm, Morecambe Bay, um, Oxford and in other places. I think there's something here about mothers don't totally understand mothers. Want to be heard they are saying. But sometimes because of how the system is. And I think Baroness Amos explained it really well earlier when she talked about. We need a framework there. People don't know how to measure it against anything because there's nothing to measure it.
Would you agree that that is an issue or not?It's just a yes or a no?
The the mother in. And, and sometimes it leads to the conclusions that were found in places like Nottingham, Malcolm, Morecambe Bay, um, Oxford and in other places. I think there's something here about mothers don't totally understand mothers. Want to be heard they are saying. But sometimes because of how the system is. And I think Baroness Amos explained it really well earlier when she talked about. We need a framework there. People don't know how to measure it against anything because there's nothing to measure it.
Would you agree that that is an issue or not?It's just a yes or a no?
10:28
10:28
10:28
Speaker 10
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Speaker 10
Fair enough. That's a good answer. Or a final answer. And, Baroness Amos, my last question or second to last question. It's about the black maternal health report. And thank you for speaking to me before you even started this. We did the report last September. It was. And one of our key items was about cultural competency training. And we really wanted the Royal College of Midwives, the NMC, NHS, to really look at this training.
Um, but government did not commit to it at that point. Um when we got the recommendation. So in your view, following the publication of um these reviews, is there any appetite in the system?That's the first point. And what is the risk of not doing it now?
Um, but government did not commit to it at that point. Um when we got the recommendation. So in your view, following the publication of um these reviews, is there any appetite in the system?That's the first point. And what is the risk of not doing it now?
10:30
Speaker 4
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Speaker 4
Uh, so we recommend, um, so thank you for the question. And, um, training is absolutely important. Um, but we recommend a review of anti-racism training because there's something about the quality and impact of it. I think we really need to address, I mean, uh, you know, asking people to do, you know, an hour, uh, every couple of weeks online. Um, it's just not going to deliver the kind of cultural change that is being looked for. And we recommend something even before that, because what we found in some of the trusts was just, um, an inability to even start a conversation about the impact of racism and discrimination in their organisation.
Uh, and if you're not actively having those conversations, then even with the training, uh, the kind of cultural change that you're looking for will not happen. So yes, I do think there's an urgent need for cultural competency training, but I think it has to be the right kind of training. Um, it has to have been tested. Uh, we should not just be rolling out training. Uh, that is not having the desired impact.
Uh, and if you're not actively having those conversations, then even with the training, uh, the kind of cultural change that you're looking for will not happen. So yes, I do think there's an urgent need for cultural competency training, but I think it has to be the right kind of training. Um, it has to have been tested. Uh, we should not just be rolling out training. Uh, that is not having the desired impact.
10:31
Speaker 10
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Speaker 10
Do you believe this is my last question?Do you believe the training should be, um, developed?How after you have the, um, commissioner that you've talked about, um, in the long term, or is this something we should be doing urgently now to get it in place even before the reference group, the, um, the, the, I can't remember the name of the. task force, the task force before they actually.
10:31
10:32
10:32
Speaker 4
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Speaker 4
Race and health observatory that are doing, um, that I think speaks to some of this. So there is, there is work to tap into as well as new work to be done. And that work can be ongoing. Now. It does not have to wait. This is always going to be an issue for trusts and NHS organisations. Um, so let's get on with it now.
10:32
10:32
Speaker 11
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Speaker 11
Thank you. I'm going to talk about workforce in a second. But one thing that strikes me is that fundamental to a lot of what's been said. And also the report itself is just a breakdown of the, uh. Doctor patient slash midwife patient relationship. Um, and that kind of tallies with what, you know, people I know say about, you know, birth plans have not been looked at and so forth. Do you think that's the case?And do you think that we need a fundamental cultural reset, or do you think it's just as a result of the over pressures on midwifery and obstetrics?
10:33
10:34
10:34
10:34
Speaker 3
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Speaker 3
So, so in terms of, um, those, in terms of the workforce and those relationships, firstly, we saw very good examples. We saw staff that were working. That's midwives, obstetricians, maternity care support workers, anaesthetists right across the board working really hard to build those meaningful relationships and have those meaningful conversations. What we heard time and time again was that due to those staff pressures, and particularly, for example, the durations of antenatal checkups, they are just not long enough to be able to have those meaningful conversations and build those relationships.
So, for example, you've mentioned someone's already mentioned about interpreters. So in primary care, there's a standard when you're working with an interpreter, you have double the length of the appointment that has never been applied to maternity services. And that cannot help develop those relationships.
So, for example, you've mentioned someone's already mentioned about interpreters. So in primary care, there's a standard when you're working with an interpreter, you have double the length of the appointment that has never been applied to maternity services. And that cannot help develop those relationships.
10:35
10:35
Speaker 3
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Speaker 3
In terms of the return to case holding, um, we strongly recommend really good putting your efforts in to strong continuity during the antenatal period and the postnatal period. When it comes to organisation, particularly around midwives, there is you should be able to organise that. A midwife does the same clinic on the same day every week. It shouldn't be that difficult. And then sees sees the women back at home. We are not recommending Intrapartum continuity. That was a tempted with great efforts after better births in 2016.
10:35
Speaker 11
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Speaker 11
I'm going to move on to the questions I'm supposed to be asking. Um, but I just thought that just struck me as one of the things going on. Um, so obviously the, um, you've talked about the need for government action to ensure clinical capacity and escalation pathways, um, including at weekends. Is that possible given the other pressures on maternity at the moment.
10:36
Speaker 2
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Speaker 2
Start. Um, so of course what we found again was huge variation across the country in terms of seniority of cover, particularly out of hours. Some places, of course, there is the availability of senior. Um, and of course senior can mean very senior residents. It can mean consultants often where you had the patchy coverage, particularly out of hours when you looked at the workforce, they were trusts that had difficulty in staffing their rotas as a minimum. Um and Baroness Amos spoke to this in terms of the geographical challenges for that many of the trusts experienced.
So not just in terms of their demographics, but in terms of recruitment, recruitment at midwifery level, recruitment at doctor level, and also the allied specialties that are that are required.
So not just in terms of their demographics, but in terms of recruitment, recruitment at midwifery level, recruitment at doctor level, and also the allied specialties that are that are required.
10:37
Speaker 11
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Speaker 11
So very quickly, obviously, um, but you talked about the NHS workforce plan. It's probably too late for us to influence that. But actually given the, um, the cost of training for an individual, do you think that training for midwifery is currently an appealing thing?Uh, and particularly given the pressures for, for a young person to go into right now.
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10:37
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10:37
Speaker 3
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Speaker 3
Yeah, I would say we have some of the best midwifery education in the world still, which is um, regulated by, by the NMC and delivered through very high calibre training courses in his and other places. There is no shortage of people wanting to be a midwife, despite all the publicity and all the pressures that they are well aware that they'll be entering into. You're probably asking the wrong person because of course, I'm from Wales, where if you train for an NHS position, the government pick up, um your your tuition fees and it's not in the report, but of course I would, I would strongly support that.
So we need to be supporting our students. We need to be looking at all the variety of, of ways to train individuals.
So we need to be supporting our students. We need to be looking at all the variety of, of ways to train individuals.
10:38
10:38
Speaker 3
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Speaker 3
Retention is. Is absolutely a problem. Um, and particularly what we're seeing, we need to make changes so that, you know, the retirement age for NHS staff coming in now is 67. We need careers to restructure careers so that we can give them longevity. We need good preceptorship programs to support our more junior staff. And we need to there is a peculiar issue.
10:39
10:39
Speaker 3
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Speaker 3
So in the workforce plan, we particularly need to be looking at careers for midwives, which means they can progress their career into specialist roles but retain a clinical, um, hands on, um, component to that. So we see two, what we, what's happening at the moment is particularly out-of-hours maternity is a safety critical service that runs 24 hours a day, seven days a week. And many of our senior midwives finish work at 5:00. Um, and the units are currently out of hours being staffed by relatively junior staff who are excellent, but they need support and we need to restructure those careers to, to support our junior staff, give postgraduate training to midwives, which is currently more or less completely lacking.
10:39
Speaker 11
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Speaker 11
Baroness Amos's report notes that 67% of midwives are experiencing burnout. Um and 65% of doctors are at risk of burnout. Um, I should declare an interest. He used to work for the GMC and work on the National Training Survey. Um, last year it found that 63% of trainee doctors in obstetrics and gynecology, um, had a. Heavy or very heavy workload compared to 42% in the rest. Um, what can be done to support our trainee doctors and midwives?Um, just to make the training pathways safer.
10:40
10:40
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10:40
Speaker 4
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Speaker 4
Um, I think in terms of that, uh, general support, one of the things that we say in our report is that it's important to look at, uh. The range of what our expectations are, um, of our doctors and midwives to make sure that there is sufficient time for them to do the things that we want them to do, particularly around the areas of listening, tackling racism and discrimination and so on, and making sure that when we do the rotors, um, that, uh, and also when we do appointments, that sufficient time is built into those at the moment, what you have is a system where, uh.
Everyone is expected to meet standards, to have long conversations in very short periods of time. So it puts pressures both on the women and families, and it puts pressures on the doctors and the midwives.
Everyone is expected to meet standards, to have long conversations in very short periods of time. So it puts pressures both on the women and families, and it puts pressures on the doctors and the midwives.
10:41
10:41
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10:42
Speaker 8
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Speaker 8
It's all important stuff. As we prepare for panel two, it's worth saying to MPs. And also, um, Donna, we are running significantly late and it will not have escaped everyone's notice. There is a valedictory Prime Minister's questions that some may or may not want to go to. Um. So to that end, I'm going to dive right in. Welcome Donna Ockenden. Thank you. Such a pleasure to have you with us.
Thank you very much. Um, I'm just going to get cracking. Um, your report was. Heartbreaking to read. Um, I can't imagine even what you went through, but more especially, the families will have gone through in its preparation. Um, could I just ask you to perhaps reflect to us what were some of the challenges that you faced in pulling it together and, you know, sort of what, what choice things are you very keen. It was a massive report talking to thousands of families.
But but what does it boil down to in the end for you?
Thank you very much. Um, I'm just going to get cracking. Um, your report was. Heartbreaking to read. Um, I can't imagine even what you went through, but more especially, the families will have gone through in its preparation. Um, could I just ask you to perhaps reflect to us what were some of the challenges that you faced in pulling it together and, you know, sort of what, what choice things are you very keen. It was a massive report talking to thousands of families.
But but what does it boil down to in the end for you?
10:44
Speaker 13
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Speaker 13
Um I think chair, it boils down to two very similar things. Lack of listening to women and families, but also lack of listening to staff. And this is where Nottingham was different from Shrewsbury. Um, some of you may have seen my presentation to the task force last week where we showed that what staff on the ground were saying was almost identical to that which women and families were saying. Secondly, then I think it's really important to say, um, we all have to be born.
And at some point we all die. And we were deeply, deeply shocked when 18 families came forward to raise concerns about after death care, that opened up a new avenue that I never thought my team and I would have to go down. Um, that's now, um, I hope leading to national, uh, work. And I think what is really, really important as well is the pressure that ordinary staff on the ground are under on a daily basis. So we spoke to more than 830 ordinary staff on the ground, midwives, obstetricians, anaesthetists and so on.
Um, there were disappointing numbers of former senior leaders that came forward. But what those staff that did come forward, um you know, described years upon years of raising concerns right up to board level, really brave midwives, obstetricians, support workers and so on. Um, and just being disregarded in the same way that women were.
And at some point we all die. And we were deeply, deeply shocked when 18 families came forward to raise concerns about after death care, that opened up a new avenue that I never thought my team and I would have to go down. Um, that's now, um, I hope leading to national, uh, work. And I think what is really, really important as well is the pressure that ordinary staff on the ground are under on a daily basis. So we spoke to more than 830 ordinary staff on the ground, midwives, obstetricians, anaesthetists and so on.
Um, there were disappointing numbers of former senior leaders that came forward. But what those staff that did come forward, um you know, described years upon years of raising concerns right up to board level, really brave midwives, obstetricians, support workers and so on. Um, and just being disregarded in the same way that women were.
10:45
Speaker 8
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Speaker 8
Um, and of course there is a, you know, several police investigations underway. We will have to be very careful in our questioning, um, today that we don't stray over that. Um, you'll have seen an intervention by the former secretary of state where Streeting, he wrote to us to say we should be using our privilege to both. Name and shame, but also to call some of those executives who refused to give you evidence in front of us. Um, I wanted to ask you straight up, do you think that that is a good idea, that something we should look at, but also, perhaps even more importantly, what did what was missing from your report by them not giving you evidence?What did you hope to hear from them that you feel might have just not been reflected in your work?
10:46
Speaker 13
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Speaker 13
So I think the difference between staff on the ground who are living the reality of, in most cases, trying to deliver the best care they can. Um, and then executive leaders, and I would stress these are recent former executive leaders. I want to be really, really clear that all of the, um, executives at the trust came forward as requested. Clearly there's going to be a difference in, in focus because, uh, you know, a recent former executive leader is going to have been responsible for the leadership of the trust, hearing staff concerns, hearing concerns from women and families.
So there would have been an extra strand of information that we would have wished to have got from those former leaders that we didn't. I I'm glad, I'm grateful, chair, that you have mentioned the police investigation. So I don't think that I should comment any further on who may or may not have come forward, because I'm still awaiting, um, police advice on that.
So there would have been an extra strand of information that we would have wished to have got from those former leaders that we didn't. I I'm glad, I'm grateful, chair, that you have mentioned the police investigation. So I don't think that I should comment any further on who may or may not have come forward, because I'm still awaiting, um, police advice on that.
10:46
Speaker 8
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Speaker 8
Understood. And we'll leave that alone. Um, so you've seen, um, Jim Mackey, uh, put out a ten point urgent, uh, maternity plan following the publication of your review and then also the Amos review, which was, um. More or less concurrent. Did you speak to him about the plan?Do you think the plan is the right one?What involvement did you have?
10:47
10:47
Speaker 13
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Speaker 13
I think that what I would say, and I have said this very clearly, um since my report was published, is we don't have the luxury of time now. So since the, I mean, the current conversation, as I understand it, is that the task force is going to take up to six months for an action plan. And I think what I what I would say, having heard from thousands of families, colleagues on the ground across all the professions, and I mean thousands since we published on the 24th of June, is that I think we know what we need to do to improve upon perinatal safety.
So I did urge government to move at pace. Um, you know, we set out a really and I do not use the word recommendations. By the way, we set out a really comprehensive suite of immediate essential actions agreed by families, royal colleges, and so on. Back in 2022, partial introduction even though the then Secretary of State.
So I did urge government to move at pace. Um, you know, we set out a really and I do not use the word recommendations. By the way, we set out a really comprehensive suite of immediate essential actions agreed by families, royal colleges, and so on. Back in 2022, partial introduction even though the then Secretary of State.
10:48
10:48
Speaker 13
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Speaker 13
Right. So my honest belief is that had we maintained the Secretary of State at the time, um, the right hon Sajid Javid MP, I think we'd have got there because he took enormous amounts of time to understand, you know, what my team and I were saying, we'll all remember this. There was a lot of churn and change at the top. I think now I am working with for my 12th Secretary of State for health since 2016, which is obviously of concern. So I think whenever there is that change, there is a risk that we lose our way, even though actually we know what our way needs to be.
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10:49
Speaker 1
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Speaker 1
Chair. Um, very quickly as I said to us I represent. A. In Sussex and you're due to commence a review in October. Um I think with the families in Sussex. Um University hospital Sussex have obviously taken on, as I said, the recommendations from the review and have looked at your Nottingham review. Um there's over 100 recommendations from both there on a 100 day sprint for the review. Just talking about what your review is going to bring to Sussex.
Um and how you've talked about you think you've seen, you've spoken to so many people, you sort of are seeing similar patterns, horrific tragic patterns. So for the families in Sussex and for the teams in Sussex and the other reviews that are going to happen as well, the additionality of those reviews, you can just talk to that a bit. That would be great.
Um and how you've talked about you think you've seen, you've spoken to so many people, you sort of are seeing similar patterns, horrific tragic patterns. So for the families in Sussex and for the teams in Sussex and the other reviews that are going to happen as well, the additionality of those reviews, you can just talk to that a bit. That would be great.
10:50
Speaker 13
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Speaker 13
Absolutely. So I think that and Ockenden review and there are hundreds of people behind me, by the way, in my team, um, has two. Purposes. First of all it is to find answers for families that they may not yet have had, but equally something that we've done in the last three years in Nottingham is talk to huge numbers of staff. And I can tell you that University Hospital Sussex staff are already coming forward in large numbers to say, can we talk to you and your team, Donna?And then we have for the last three years and it will be rolled out in Sussex.
We didn't just hand Nottingham a great big purple report. We had bimonthly every two months. Learning and improvement meetings where we fed back to the trust, the things we were hearing from their own staff and from families they needed to do. And then we looked at their evidence on an ongoing basis. So I can say with confidence that Nottingham has actually put in place a lot of the learning throughout the process. It isn't about waiting for three years for Ockenden to finish her work.
And I, you know, as a local MP, I'm sure we'll be in touch on a regular basis. I wanted to reassure Sussex MPs and actually Leeds MPs about the way that we do things.
We didn't just hand Nottingham a great big purple report. We had bimonthly every two months. Learning and improvement meetings where we fed back to the trust, the things we were hearing from their own staff and from families they needed to do. And then we looked at their evidence on an ongoing basis. So I can say with confidence that Nottingham has actually put in place a lot of the learning throughout the process. It isn't about waiting for three years for Ockenden to finish her work.
And I, you know, as a local MP, I'm sure we'll be in touch on a regular basis. I wanted to reassure Sussex MPs and actually Leeds MPs about the way that we do things.
10:52
Speaker 1
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Speaker 1
And just very quickly, the same question I asked Baroness um Amos around complimenting, uh, the recommendations in her review alongside the recommendations that will come out of doubtless your Sussex and Leeds review and previous reviews. Do you see large areas of overlap and complimenting recommendations for the trusts and, you know, for the families to hear about improvements?
10:52
Speaker 13
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Speaker 13
Yes. I think that having been in and around perinatal services now since 1989, which is a very long time, um, I think that we often know what we need to do, but we simply don't get on and do it. And I think that that is one of the issues we face at the moment, albeit I still think it's absolutely vital that staff on the ground get to have their views heard. And we will work very hard with staff on the ground and families deserve answers.
So maybe I think there's something about the system that means that parents are waiting years for answers, and still staff voices are silenced. So we've got to get that right.
So maybe I think there's something about the system that means that parents are waiting years for answers, and still staff voices are silenced. So we've got to get that right.
10:52
Speaker 8
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Speaker 8
Um. Baroness. Um, spoke about the task force will have the job of prioritizing what they go after first, second, third for Paulette and I are on and just left the room. But we sit on the one of the expert reference groups that's going to feed in. Um, what should we be feeding into?That task force is the top priority that we should be going after. We need to do it. All that was made clear, and I'm sure you'd agree, but what's the top priority in your.
10:53
Speaker 13
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Speaker 13
Okay. So I think that there are priorities, chair, that are interlinked. First of all, listening to women, families and staff on the ground is one absolutely vital golden thread. But we're not going to achieve that until we have a comprehensive perinatal. So it's not about midwifery. I'm a midwife and a nurse. It's not about midwifery and nursing. Perinatal workforce tool that tells us what we need. So, you know, we know that we've got gaps in rotas across very many obstetric rotas, vacancies in terms of midwifery, neonatal units under significant pressure.
We've I don't believe we've ever done that. Perinatal workforce tool. And that needs to be funded. And then you might say to me, well, do you know where's the money?We're already spending vast amounts of money. Um, in terms of compensation for harm, when actually none of the money in the world is going to bring back, um, what families have lost or compensate staff for the moral injury that they suffer on a daily basis. And I've heard from hundreds of doctors and midwives, hundreds in the last four weeks just saying, we don't know how much longer we can take this obstetricians saying, I'm not sure now, Don, that I can actually complete my training and midwives saying to me, is tomorrow going to be the day I hang up my uniform for the last time?So time is not on our side.
Chair.
We've I don't believe we've ever done that. Perinatal workforce tool. And that needs to be funded. And then you might say to me, well, do you know where's the money?We're already spending vast amounts of money. Um, in terms of compensation for harm, when actually none of the money in the world is going to bring back, um, what families have lost or compensate staff for the moral injury that they suffer on a daily basis. And I've heard from hundreds of doctors and midwives, hundreds in the last four weeks just saying, we don't know how much longer we can take this obstetricians saying, I'm not sure now, Don, that I can actually complete my training and midwives saying to me, is tomorrow going to be the day I hang up my uniform for the last time?So time is not on our side.
Chair.
10:55
10:55
Speaker 14
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Speaker 14
Thank you, chair, and good morning. Um, I'd just like to focus a little bit on the issue of accountability. Um, because I understand that your review highlighted, um, sort of an impact of poor organisational culture and leadership. Um, what does sort of what does accountability in this space mean to you?
10:55
Speaker 13
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Speaker 13
Um, I think that it is about truth telling. I think it's about hearing, I think it's about taking the action that one is in public office for. Um, and I think then there has to be a sense of responsibility. If we just take, you know, the aspect of after death care in Nottingham, there has to be accountability for what happened to those families. Um so I think it is a, it is a myriad of things brought together under one umbrella.
10:56
10:56
Speaker 13
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Speaker 13
I think that it has. So if I give you the example and it is in the report where, you know, 50 midwives and maternity staff wrote to the chairman of the board in 2018, they didn't get a response, so they tried again in 2019. Um, and they were so worried, they told the board that babies would die in 2018. Nothing was done in 2019. In Nottingham, an inquest got halted, which is really unusual, and the coroner read out this letter so that the coroner could be supportive.
Both the families and the staff on the ground. That is an absolute failure of accountability.
Both the families and the staff on the ground. That is an absolute failure of accountability.
10:57
Speaker 14
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Speaker 14
And, um, we heard in the previous panel that um, from I think it was Christina Koch, she said that, um, there was a question as to whether you can have outstanding maternity services in, in like a poorly performing trust. And I think the answer was, if there is, it's despite the system not because of it. Um, and it's about a leadership at trust level rather than necessarily within a maternity service itself. Is that something that you would echo that if it's a poor leadership at the very top of trusts, or is it more looking at where the maternity services operate?
10:57
Speaker 13
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Speaker 13
I think it's both. I think it's both. I know of some outstanding maternity units with outstanding leaders. I have, having been around as long as I have, I have I know of many outstanding board leaders, but what I will say is that if we take obstetrics and midwifery. Now, I know some brilliant, many, many brilliant consultant obstetricians, consultant neonatologists and they are saying to me, we do not want these leadership positions. You know, I spoke to a doctor last week who said to me, you know, maternity governance broke me.
I had to walk away. So I think leadership is there on the ward, on the day, interacting with women right up to board level and then commissioning level. So there is there should be seamless leadership, you know, literally from ward to ward.
I had to walk away. So I think leadership is there on the ward, on the day, interacting with women right up to board level and then commissioning level. So there is there should be seamless leadership, you know, literally from ward to ward.
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10:58
Speaker 13
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Speaker 13
Pressure the pressure?So there's insufficient resources?So to be clinical director, obstetrics or clinical director for maternity governance, if you are very, very lucky, you may get one day of time, which is in no way sufficient. Some in some trusts, they're given half a day of time, you know, so these leadership positions are they're not respected. And as I say, it breaks colleagues, which is really worrying.
10:59
Speaker 14
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Speaker 14
Um, you have highlighted in your report that all the issues you I think you said are particular concern is that many of these issues were already known, um, and that there had been several attempts to flag them throughout the years. Um, is the current regulatory sort of framework, is it fit for purpose?
10:59
Speaker 13
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Speaker 13
That's a really good question. We have seen throughout the duration of the Nottingham report some improvement um in the relationship between. The main regulators, GM, GMC General Medical Council and Nursing and Midwifery Council and families. But that has been hard. One that has been hard work, if I'm honest. Um, I'm confident I've met with the GMC, NMC QC yesterday that we are going to start the Leeds and Sussex reviews in a different place with the regulators on the front foot.
But I'm going to speak as I find, which is it's been extremely hard work to get to this place. It's taken three years um of concerns raised by families, concerns raised by me. I think we are on last chance saloon. We are going to push really hard to get this effective relationship between families and regulators. For Sussex and Leeds. I'm pretty confident we can, but I will have my eye on it, believe me.
But I'm going to speak as I find, which is it's been extremely hard work to get to this place. It's taken three years um of concerns raised by families, concerns raised by me. I think we are on last chance saloon. We are going to push really hard to get this effective relationship between families and regulators. For Sussex and Leeds. I'm pretty confident we can, but I will have my eye on it, believe me.
11:00
11:00
Speaker 13
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Speaker 13
MM. So it's really interesting if we take Nottingham as an example, um because that's I know best and I'm most up to date with um there were lots of opportunities for regulators to understand. HMM. Coroner in Nottinghamshire. It's really, really active. Lots of um inquest verdicts where negligence was ruled deep concerns about the care. And yet they weren't, as regulators aware of those cases. And I do know that. MM.
Coroner invited the regulators on multiple occasions to attend inquests. So yeah they there were lost opportunities. I would say significant.
Coroner invited the regulators on multiple occasions to attend inquests. So yeah they there were lost opportunities. I would say significant.
11:02
11:02
Speaker 13
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Speaker 13
Um, I think they haven't to date, but there have been some very honest conversations. Um, families and regulators, myself and regulators. I do see that we've got green shoots of recovery, but I will be keeping a very close eye on it through Sussex, uh, through the duration of the Sussex Review and the Leeds review.
11:02
Speaker 14
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Speaker 14
Thank you. And just before I hand back, because I'm quite, I'm always quite interested in where the accountability lies in a healthcare system. And I think, um, for a sort of constituency MP and a service user, you can, um, it's quite hard to see if you have people who are quite often paid quite a lot of money within a system that fails and continues to fail and then seemingly just fail upwards in that sort of career progression, do you think there is an issue?Because I don't want to go into individual sort of levels here, because there is an ongoing police investigation.
Um, but it feels like you're less saying that there is individual failures of leadership and more that the system itself is not set up to support those leadership roles to be effective. Is that is.
Um, but it feels like you're less saying that there is individual failures of leadership and more that the system itself is not set up to support those leadership roles to be effective. Is that is.
11:03
Speaker 13
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Speaker 13
That right?No, it it's it's both, um, I think we are all accountable for what we do. From the minute I open my eyes in the morning, I am accountable for the work that I do. And I think all of us in public service in the NHS, whether we're in, you know, in leadership roles or whether we are that midwife on the ground, that obstetrician on the labour board, we we are all accountable. But I don't think that the system, as it's currently set up, um, is supporting staff to always be able to do the best they can and the way they want to deliver it.
11:03
11:03
Speaker 13
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Speaker 13
So I think the key issue is that we need to look at why in this country, we are allowing so much maternity harm. And we're talking billions of pounds, um, to happen. Why we are allowing so many staff to feel damaged by their everyday working life. Um, and just say the tide has now got to turn. Absolutely. It has to turn.
11:04
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11:04
Speaker 6
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Speaker 6
Thanks very much. Um, uh, so. We've heard a lot in from Barren review your work as well about the failure to kind of listen to women and families. I think because of time in the previous panel, we touched a lot about how what practically this means in consultation and conversations about birth choice and how it can be affected. I want to focus more systematically with you, if that's okay, just because of time. Um, though, if you want to add anything about, about that issue, kind of how you build it into decision making in clinical practice, very happy to hear it.
But more generally, have you got thoughts how patient and family voice can be embedded more systematically within trusts, within unit decision making, within governance arrangements. Is that something you think needs to happen?
But more generally, have you got thoughts how patient and family voice can be embedded more systematically within trusts, within unit decision making, within governance arrangements. Is that something you think needs to happen?
11:05
Speaker 13
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Speaker 13
Yeah, absolutely. So I think. From the thousands of families that we spoke to, there were there were countless, um, illustrations of women and husbands and families not being listened to. Now that can be a time issue without, without a doubt. So, um, you know, not having time to care is, is really, really important. And it is, we have to be honest, it's a daily feature of life in, in perinatal care, um, in, in this country. Um, but again, it's about resetting the ship, you know, we heard in Morecambe Bay, we heard in East Kent, we heard in Shrewsbury that these things were happening.
And what I would say is we simply haven't done enough to turn that ship around. Still.
And what I would say is we simply haven't done enough to turn that ship around. Still.
11:06
Speaker 6
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Speaker 6
Do you think on trust boards, on their governance, governance arrangements, a family is often represented. A parents represented. In my experience, many of the governance boards tend to be quite older people, maybe retired people. Do you think right from the top in governance arrangements of trusts and the governance of units, are are there peer groups?Are there family groups?Are they embedded in peer reviewing?The unit for family centered practice, do you think, as well as just hearing the mother and family's choice about their birth, do you think the voice of families and parents kind of is reflected right through how how trust to run?
11:06
Speaker 13
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Speaker 13
So I think something that maternity perinatal care doesn't know. And when we, you know, we had contact with families over a three year period in Nottingham because now women and babies and families are discharged so early from maternity care, sometimes it was up to me and my team to tell the trust. Well, are you not aware what has happened to Mrs. Jones or Mrs. Ali?Do you not know that she's at home, you know, struggling with the most appalling health problems?And so we had to set up in Nottingham and we did make some differences and escalation pathway for urgent care needs that these families needed, whether with um brain injured children, mothers needing colorectal support, that the trust just was completely unaware of.
Now we've seen some real improvements in Nottingham in terms of engagement with local communities. But when I got to Nottingham late 2022, I said, well, how do I meet with the Roma community?How do I meet, you know, with the Jewish community?How do I meet with the most disadvantaged women?And it was like blank face. And so I had to go across the city and the county and find these groups for myself, which I have done, and I've reintroduced them to the trust, but they weren't in the best place at the start of this review.
Now we've seen some real improvements in Nottingham in terms of engagement with local communities. But when I got to Nottingham late 2022, I said, well, how do I meet with the Roma community?How do I meet, you know, with the Jewish community?How do I meet with the most disadvantaged women?And it was like blank face. And so I had to go across the city and the county and find these groups for myself, which I have done, and I've reintroduced them to the trust, but they weren't in the best place at the start of this review.
11:08
Speaker 6
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Speaker 6
Are there any systematic approaches or that you've seen that work?Well, I mean, just fundamentally a trust board. They probably weren't worried about their A and E times their bed occupancy rates. They're under huge financial pressure. It sounds like. What's needed is quite a fundamental change in the risk that they're looking at who they're hearing, how they're speaking to people to get their feedback.
11:08
Speaker 13
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Speaker 13
Yes. I mean, what I have found in my years and years and years of, um, working with community groups, listening to women, listening to families is, um, the NHS almost needs to turn itself on its head rather than say, well, women over there are hard to reach. Absolutely. They are not. If women and families are asked, they will give freely of their experience. They will engage, they'll engage, they'll put huge effort in. But I think there is a tendency to go over there hard to reach.
That's not a word that a phrase that I will use at all.
That's not a word that a phrase that I will use at all.
11:09
Speaker 6
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Speaker 6
And where people have turned it around, where people do listen are just to highlight, is there anything they specifically do?Sure. There's time on the board agenda. Is it having a representative midwifery?You know, there's obviously normally a chief nurse role, but a specific midwifery voice at trust level, like what?Is there anything that particularly work in hearing staff or patient voice?
11:09
Speaker 13
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Speaker 13
Yeah. So I spent many, many years as a chief midwife more than I can count. I think that, um, relationship between chief nurse, chief midwife, medical director is absolutely vital. And I've seen many, many, um, settings where that works very well. Um, and then it is also about ensuring that the services on the ground are resourced. And I think it's really important how much we expect in the NHS of women and families to do free of charge. I mean, some of the Nottingham families have worked virtually full time supporting community engagement, making sure that they, you know, liaise with other families who often wouldn't be heard.
But we're not resourcing that at all.
But we're not resourcing that at all.
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Speaker 15
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Speaker 15
Thank you very much. You said a moment ago that that staff feel feel damaged by their everyday working lives. There's clearly, um, a crisis in staffing levels across many of the settings that you've, you've reviewed, including, of course, Nottingham more recently. And I, and I note that the Royal College of Midwives recently, in a survey published last last month showed that um 70. 7%. So more than three quarters of those who responded said that they did not feel that their team or unit was was safely staffed.
Something for us all to worry about. And 93% felt that staffing levels affected the quality of care they were able to, to provide for women and babies. I mean, that that is an extremely shocking and presumably that is at the at the base of, of, of why circumstances such as that at Nottingham arise. So, so so how, how do we overcome that and how do we attract the right people into into post and sufficient of them to be able to support each other?
Something for us all to worry about. And 93% felt that staffing levels affected the quality of care they were able to, to provide for women and babies. I mean, that that is an extremely shocking and presumably that is at the at the base of, of, of why circumstances such as that at Nottingham arise. So, so so how, how do we overcome that and how do we attract the right people into into post and sufficient of them to be able to support each other?
11:12
Speaker 13
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Speaker 13
Thank you very much. So I think that there there are a number of issues here. There is recruitment, but then there has to be retention. So again, I talk to midwives and doctors on a daily basis. You know that in a 12 hour shift they haven't even got time to go to the loo, you know. And so, um, I, I think the big issue is we have to, and we don't have time to waste. We have to develop that perinatal workforce strategy that tells us these are the number of obstetricians.
These are the number of obstetric anaesthetists. These are the number of midwives. And you know, and until we do that, we don't even understand yet. I don't believe what we need. And and I think that that is something that is it can't be tolerated anymore.
These are the number of obstetric anaesthetists. These are the number of midwives. And you know, and until we do that, we don't even understand yet. I don't believe what we need. And and I think that that is something that is it can't be tolerated anymore.
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11:13
Speaker 13
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Speaker 13
Need to I well, it was an immediate and essential action from Ockenden. Not a recommendation. And that was something that we worked on with all of the Royal colleges, midwives, obstetricians, anaesthetists, and so on and so on. And you know, I'm a midwife, but it wasn't about me being precious about midwifery. It was saying maternity is not. An island. There's a big team of people who are required to deliver safe care. And I don't think we've done enough towards that yet, but I, I am confident that the Royal Colleges were absolutely involved in that in the drafting and crafting of that immediate essential action.
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Speaker 15
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Speaker 15
No, no. And then in would that be in relation to the number of antenatal and postnatal beds and, and in relation to that. I mean are there sufficient. Because I mean in many settings, it seems to me that often women are discharged in antenatal circumstances when perhaps that is unwise simply because there are insufficient beds.
11:15
Speaker 13
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Speaker 13
Yes. I think that what I hear I saw it in Nottingham, but what I hear from all my colleagues and I, you know, I've got colleagues right from Newcastle, right down to Cornwall. Mhm. Um so what I hear is that, as one doctor said to me last week, the thing is we're trying to deliver safe care with at least one hand tied behind our back. This is a real doctor on shift last week because, um, they haven't got sufficient perhaps neonatal cots.
They haven't got, you. The infrastructure is was lovely in 1998 or whatever. So I maternity. Perinatal estates are also a vital importance. I spoke to a doctor not very far from your constituency. Um and he said to me, do you know I was doing emergency drills and I had to take my junior doctors out on the patio off the bereavement suite and hope that the bereavement suite wasn't needed because it didn't have anywhere else to take my resident doctors to train them in emergency drills.
That was last week.
They haven't got, you. The infrastructure is was lovely in 1998 or whatever. So I maternity. Perinatal estates are also a vital importance. I spoke to a doctor not very far from your constituency. Um and he said to me, do you know I was doing emergency drills and I had to take my junior doctors out on the patio off the bereavement suite and hope that the bereavement suite wasn't needed because it didn't have anywhere else to take my resident doctors to train them in emergency drills.
That was last week.
11:16
Speaker 15
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Speaker 15
Yeah. So so I mean, the the report that you produced obviously had some shocking and extremely distressing. You know, cases, um, I mean, how. It's very difficult to say, but I mean, in how many cases would you say that that was driven by or largely driven by not just an attitude and a way of, of, of, of speaking to, to patients, but, but driven by the pressure of, of inadequate staffing levels.
11:17
Speaker 13
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Speaker 13
So inadequate staffing in Nottingham was well known by the board going and they obviously multiple iterations of, of that board going back at least to 2010. Staff were raising concerns going back to then parents started whistleblowing really in 2016. So there were there were many years of inaction. However, what we also need to be clear about is that there was a cabal of people in that unit who led the way, and both staff and families, said a small group of people were allowed to infect the unit.
And again, staff.
And again, staff.
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Speaker 13
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Speaker 13
Yeah. So, I mean, that's a very strong word. Infect the unit. But staff said that families said that without ever having talked to each other in the middle. So I, I think that behaviours play an important part. Poor behaviour, poor behaviour that was tolerated definitely played an important part. But it's important to say that staffing was a long term known board issue with no action.
11:19
Speaker 15
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Speaker 15
Right. And then in terms of the government's response and the, the the proposal to, to invest, uh, 10.6 million into the recruitment of additional band five midwives, I mean, band fives are paid at £31,000. I mean, how many I mean, are you going to attract people of the right um capacity. Um, you know, the right kind of people into, into that post with pay levels at that level.
11:19
Speaker 13
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Speaker 13
So band five midwives, as I understand it, they're very newly qualified. So I know from my experience in Nottingham that um, when one invests in large numbers of newly qualified midwives, you have to have, you know, the Preceptorship support programme because they are very, very junior. Now, I've seen some good practice in that. So um, after Shrewsbury University College Hospital, London invested in what they called um Ockenden retention midwives, where very senior midwives and I checked recently, those posts are still in place, um, where very senior midwives are there literally to handhold and support, um, newly qualified midwives in the first year, 18 months, um, of, of their career.
Um I, I then hear from elsewhere in the country that midwives are put under quite a lot of pressure to get, get, get their band six competencies because, you know, so I don't think that the good practice that I have seen and heard of, um, is by any means rolled out across the country.
Um I, I then hear from elsewhere in the country that midwives are put under quite a lot of pressure to get, get, get their band six competencies because, you know, so I don't think that the good practice that I have seen and heard of, um, is by any means rolled out across the country.
11:19
Speaker 15
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Speaker 15
Would you say from your experience, if I understand in the past that, um, to become a midwife, you, you, you'd become a registered nurse first and then do your midwifery as, as postgraduate and that there are a lot of experienced midwives who believe that actually being able to be trained simply as a midwife and to be working within the, the, the more limited, if you like, um, clinical perspective landscape in which one understands that that is actually, uh, created less. Less capable midwives given, given the range of complexities that they may be presented with.
I mean, is that a reasonable, given your experience?
I mean, is that a reasonable, given your experience?
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11:20
Speaker 13
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Speaker 13
I did train in the olden days, um, nurse first midwife afterwards. Um, I think there's room for both. I would like to see more registered nurses, you know, perhaps with ITU experience, surgical experience. Um join midwifery. I would very much like to see that. Um I think that we need to look very carefully at um the training program that is currently offered, um to midwives, you know, who are uh, qualified midwives as a standalone and um profession. And they don't have that nursing background.
I think there's room for both.
I think there's room for both.
11:21
Speaker 15
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Speaker 15
Right. Okay. Thank you. Just I was looking for your, your, um, facial response when the issue of, of, of, of, of doctor Kirkup and, and um, within the Amos review and the, and the issue of, uh, national ideology was, was in, was in discussion. If I, if I don't mind, if I just ask this, I mean in relation to this, given your, your perspective across the whole, the whole, um, you know, a number of inquiries. I mean, would you say that there is an issue here in relation to the fact that there are non-clinical groups that are campaigning for such things that may not be.
11:21
Speaker 13
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Speaker 13
So we use the phrase in Nottingham, a deviance of normalisation where we found quite significant evidence that women who were no longer normal were being denied the care and treatment they needed. So that's the phrase that we use deviance of normalisation. And there are lots of examples, sadly, of that with tragic outcomes in Nottingham.
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11:22
Speaker 16
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Speaker 16
Thank you very much. Um so um obviously you you've read the Amos review and you've obviously heard the evidence given today. There's obviously clearly a lot of, uh, agreement between yourself and Baroness Amos in the review. But when the standard approach to the Evening Standard approach to you, you said, I don't see anything that we didn't already know that hasn't already been spelt out very clearly. So do you think the report adds anything significantly, and how do you see it playing out and interacting with your reports and reviews?
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11:22
Speaker 13
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Speaker 13
So thank you very much. Having spent decades in and around maternity care, have this is now, um, my second Sussex and Leeds will be my third and fourth inquiry. I think that what we've amassed over many years, um, has been a vast amount of knowledge on maternity and neonatal care that we simply haven't acted quickly enough on. So I would have. I guess I, if I'd been shocked and I did read the Baroness Amos report from cover to cover, burning the midnight oil.
If I'd been shocked, then I think probably I wouldn't have been doing my job properly because a lot of what was in there, as we've said, is, um, you know, very similar. Doctor Kirkup's previous work in East Kent and in Morecambe Bay and my Shrewsbury review. Um yeah. So I think that's the issue.
If I'd been shocked, then I think probably I wouldn't have been doing my job properly because a lot of what was in there, as we've said, is, um, you know, very similar. Doctor Kirkup's previous work in East Kent and in Morecambe Bay and my Shrewsbury review. Um yeah. So I think that's the issue.
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Speaker 13
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Speaker 13
I, I can't answer that question in terms of I know that what you know, what we did. So we, um, had interaction from 2511 um cases. And also we heard from so many staff on the ground that said we were under pressure to discharge, you know, get them out the door, get them out the door. And then they were appalling behaviours that you may have seen on a recent BBC programme where extremely rude things were written on, on whiteboards in labour wards, where basically there was this culture of get them out the door.
So I think it's a you know, there are many issues, but staff told us, families told us. Um, and yeah, we believe them.
So I think it's a you know, there are many issues, but staff told us, families told us. Um, and yeah, we believe them.
11:25
Speaker 13
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Speaker 13
Okay. So again, we, uh. Heard from very many obstetricians in Nottingham. And again, my team Newcastle right down to Cornwall doctors that today will be on their labour wards will be on the labour wards at the weekend. Um and what they are saying, all of these colleagues and the hundreds of colleagues that have contacted me since is. We are spread so thinly on the ground. Where are these people going to come from?You know, I get midwives telling me on a daily basis, maybe it will be their day off tomorrow.
They'll wake up tomorrow morning. So they're on these famous WhatsApp groups when the unit is short staffed, day in, day out. They say, you know, managers, we know you've got a day off today. Any chance you can come in or you've got mandatory training tomorrow, bring in your uniform because you probably won't spend the whole day training. So the pressure that staff on the ground are under is deeply concerning.
They'll wake up tomorrow morning. So they're on these famous WhatsApp groups when the unit is short staffed, day in, day out. They say, you know, managers, we know you've got a day off today. Any chance you can come in or you've got mandatory training tomorrow, bring in your uniform because you probably won't spend the whole day training. So the pressure that staff on the ground are under is deeply concerning.
11:26
Speaker 16
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Speaker 16
Thank you. And just just to really drill down just a bit more into the denial of caesarean sections, which which you saw very clearly in your report. And um, and that may be down to clinical reasons, that may be down to ideological reasons. I think your report suggests very clearly it was ideological again. Um, if we as a committee are trying to make recommendations and we've got, on the one hand, your, your investigations and reviews, which say this is definitely a national problem.
We've got Baroness Amos review that says, well, it isn't. How do you, how do you think to to back your argument up?How do we what evidence should we be looking for to ensure that we can we can support we can support what you're saying. Where can we where can you point us?
We've got Baroness Amos review that says, well, it isn't. How do you, how do you think to to back your argument up?How do we what evidence should we be looking for to ensure that we can we can support we can support what you're saying. Where can we where can you point us?
11:27
Speaker 13
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Speaker 13
I would point you to what's called the Intrapartum, which is the Labour chapter, which gave lots of examples. The antenatal chapter, the chapter on women's voices and the chapter on staff voices. That's Nottingham. And then of course, now Shrewsbury is four years old. Um but I would say there was significant evidence there. And then of course Doctor Kirkup is a very well respected colleague and he's done East Kent and he's done the Morecambe Bay report which goes back to 2015.
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11:28
Speaker 13
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Speaker 13
So. Um, I think we'll have. We'll have to wait and see. But yes, I have spoken to women who have used all four units in Sussex and there are increasing numbers of staff coming forward. So I you know, the jury is out so to speak. Um we will approach our work with absolute diligence and we'll ensure that women and family voices and staff voices are heard and reported and acted upon.
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11:29
Speaker 13
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Speaker 13
You mean the, the taskforce creating the action plan?I, I had to speak as I find, which is I have said we don't have the luxury of six months. I don't believe you know. And that's an action plan by the end of the year. How long does it then take once the action plans out and Christmas and everything is done to then get that implemented?So I think. If we were to look at how many midwives will hang up their uniforms in the next six months, how many doctors will decide they can't do this anymore and how much harm potentially potentially could be caused?I would say we don't have six months to create an action plan.
That would be my.
That would be my.
11:30
11:30
Speaker 13
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Speaker 13
So I think it would be important for the committee to to listen to family views. And I did ask them if they would, if they were able to attend, um, as, as you requested me to, I understand where families are coming from. Vast majority of families that I have known over decades. They say they want two things. They want answers, but they also want assurance that what happened to them isn't going to happen to anyone else. And I think where they're left sitting at the moment is not enough has been done to give them that confidence.
So I do fully appreciate where they are coming from.
So I do fully appreciate where they are coming from.
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11:31
Speaker 7
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Speaker 7
thank you. Uh, really very interesting. Thank you for the work you've done. It's extraordinary and very important. Um, just to come back to the action plan and the maternity commissioner as well, I wanted to ask you about maternity Commissioner. I get the feeling with the action plan that you feel it could be written in a week.
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11:33
Speaker 13
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Speaker 13
Um, I don't know because, as I explained to Doctor Cooper, um throughout the Nottingham report, we were meeting with very senior NHS leaders. We were meeting with the trust and we were keeping them informed of our findings. So yes, that's probably the biggest. And we'll do that throughout Sussex, I promise you. Um that's probably the reason why I would say, well why are we saying we need six months to write an action plan?I think there was enough knowledge, um.
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11:33
Speaker 13
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Speaker 13
Well, we're spending the money. I think we have to be really clear. We are spending the money on the cost of harm. Not that that can ever compensate families for what they go through, but I think the money's I'm sure there could be some very clever economists somewhere who could say, well, we're spending this on harm. How do we turn that back around into better care?I'm not an economist, but I'm sure there must be a clever will and a way somewhere.
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Speaker 7
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Speaker 7
And the last quick question is I'm sorry. I should say we can have six months for the plan to be. And we've made your comments on the length of time, six months for the plan to be developed. The commissioner would only come in, um, some months after that even. Um do you think that would make it the job still doable or more challenging?
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09:15
Speaker 13
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Speaker 13
Understanding is, is that the request is for the commissioner to co-chair the task force. I think that's what I heard today, which would be a good thing with with with the Secretary of State. But I guess then they would need to be um, every. Effort made that the Commissioner wasn't then responsible for introducing work that they might not have had an influence on. So I think timings that, that, that is one of the reasons why we need to move at speed and at pace with this action plan.
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Speaker 8
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Speaker 8
Thank you, thank you. Just to follow on slightly, just to be clear, we heard from the last panel one of the powers that was suggested the commissioner should have is the to be able to compel the creation of new data sets and so on. What other powers do you think is critical?The Commissioner has that might, for example, be written into legislation?Can you be specific about that so that we can recommend that?
09:15
Speaker 13
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Speaker 13
Yes. So I was really moved to hear all the discussion, um, in the House about the Hillsborough law. So I do think that that and yeah, really moving. Um, so I do think that, um, compelling people to speak is really, really important. I think that the role has got to be resourced. I think the fact that it's on a statutory basis, a statutory footing is, you know, is, is really important. But I think the structure and underpinning it has really got to be given some considerable attention.
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