Health and Social Care Committee
Oral evidence: Maternity Reviews, HC 525
Wednesday 15 July 2026
Ordered by the House of Commons to be published on 15 July 2026.
Members present: Layla Moran (Chair); Danny Beales; Ben Coleman; Dr Beccy Cooper; Jen Craft; Josh Fenton-Glynn; Andrew George; Paulette Hamilton; Alex McIntyre; Gregory Stafford.
Questions 1-95
Witnesses
I: Valerie Amos, Baroness Amos, Chair, National Maternity and Neonatal Investigation; Dr Christine Ekechi, Expert Adviser, National Maternity and Neonatal Investigation; Professor Julia Sanders, Expert Adviser, National Maternity and Neonatal Investigation.
II: Donna Ockenden, Chair, Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust.
Witnesses: Baroness Amos, Dr Christine Ekechi and Professor Julia Sanders.
Chair: Welcome to this session of the Health and Social Care Committee, in which we will talk about the maternity reviews. On our first panel, we are delighted to have with us Baroness Amos; welcome, and thank you so much for coming to talk to us about your recent review. May I ask your colleagues to introduce themselves, starting with Christine?
Dr Ekechi: Good morning. My name is Dr Christine Ekechi. I am a consultant obstetrician and gynaecologist here in London; I was also one of the expert advisers to the investigation.
Professor Sanders: Good morning, everyone. I am Professor Julia Sanders. I am the professor of clinical midwifery at Cardiff University and one of the expert advisers.
Q1 Chair: Thank you all for being with us today. Baroness Amos, if I might start with you, when you were pulling together the review, 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? Where in the system would you highlight some resistance? I am aware that there was some.
Baroness Amos: Chair and Committee members, good morning and thank you. I will just say three very quick things by way of introduction before answering your question.
First, I thank the Committee for inviting us to give evidence this morning, and I thank the families who contributed to our investigation and, in doing so, had to recount painful, distressing and traumatic experiences. We would like to give our condolences to those families who experienced bereavement, and to thank everyone who contributed to our review.
Secondly, we did this review in 10 months and its scale is unprecedented. When we started, I did not expect that, at the end of those 10 months, we would have visited 22 hospitals across 12 NHS trusts; had over 10,500 people respond to our call for evidence, as well as over 9,000 staff; analysed 9,500 pieces of evidence; interviewed 40 national leaders; spoken to 19 MPs and had five APPG sessions; held 15 evidence panels for stakeholder organisations, particularly around inequalities because we were so concerned about what was happening; and reviewed previous recommendations and international comparisons.
In terms of the challenges, the scale of what we sought to do in a 10-month period was unprecedented. 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 in the report.
Chair: We might come back to that.
Baroness Amos: We were very clear. We have published 12 trust reports. They are a snapshot; we were in each trust over two or three days. They were not CQC-type investigations, but reflections back to the trust of what families and its own staff told us about its performance. That was a challenge, but it was a very important thing to do.
Breaking down what we had found into a set of recommendations that address the systemic challenges facing maternal and neonatal care was very challenging, because the previous investigations had all been case reviews and focused on one NHS trust.
Although we found a number of things that absolutely echo the previous recommendations, the fact that this was national and systemic in scope, and that we have taken an approach to our recommendations based on a safety-first principle, is important and different, as is our recognition that there is not one set of national standards against which maternity and neonatal care is judged. There is too much variation and way too much fragmentation in the system.
Finally, the scale of embedded racism and discrimination, as well as the issues of not listening to women and families and the lack of accountability in the system—those are all challenging. However, if all our recommendations, which interconnect, are implemented, that will make a significant difference.
Q2 Chair: We will be speaking to Donna Ockenden in panel two, but this is not the first time—her review echoed what others have heard—that executive teams in hospitals and trusts and ICB leaderships have not always fully appreciated the scale of what was happening. Did you find that in your review as well? Were there some trusts following best practice and others not? Are you willing to share some of those leadership and accountability stories that have been clearly identified in your and other reviews?
Baroness Amos: Yes. We found considerable variation and fragmentation. We found variable quality among trust leaders in terms of their assessment of what was going on in their situation, in their particular trust, and their ability to deal with it.
Chair: What do you make of OUH, for example?
Baroness Amos: May I come back to that?
Chair: Yes, please.
Baroness Amos: To go back to the generic point about trusts and what they are seeking to do, one of the things that we were very concerned about was the fact that in parts of the country, the demographic complexity—areas of deprivation and very mixed communities—is such that, in our view, those trusts need additional support. The people who are working in the trust are also the service users of the trust, so there are very major challenges there. In addition, given the layering of recommendations for local trusts to implement, there is no one national repository of recommendations and of prioritisation of those recommendations.
Chair: We will come to the taskforce and its job in a moment.
Baroness Amos: But this is not even about the taskforce; this is about how the system functions. There is no sense of what the evidence base is behind a recommendation that is being made, or of where that sits in terms of a trust’s priorities.
We saw 12 trusts, and within and between trusts there is significant variation. We saw good, poor and excellent practice in the same trust as well as between trusts. There is good practice everywhere, but there are also elements of poor practice almost everywhere, and there is no way or sense of where trusts can learn from each other where there is good practice. 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 to how they can help each other.
Q3 Chair: I must declare an interest in OUH, in that we had a baby there just over a year ago. Also, I am supporting a number of women who are going through that trust. They will be keen to hear your view.
Baroness Amos: In OUH, we saw a large number of families—I think it is the trust where we saw the largest number of families—in relation to both the John Radcliffe site and the second site. We talked to a lot of staff. We found an extremely poor estate. As an investigation team, we actually debated whether it was the worst estate that we had seen. We determined that it was not, but it came pretty low down. We found a leadership team who we felt did not understand the challenges that they faced and who were not listening sufficiently to the voices of the women and families in their communities. We recently had a feedback session with the leadership of that trust and were very impressed by the way they have taken our findings on board, have apologised to their community and are now making significant efforts to see how and what they can do to improve.
Q4 Chair: So there are already positives. I have spoken with them myself, and it is interesting that they have reacted in a very positive way to your challenge.
Our vice-chair Paulette Hamilton and I are in the expert reference group that is feeding into the taskforce; we are not on it, but we feed into it. Briefly, because we are short of time and we do want to dive into many of the other issues in your report, what advice would you give the Secretary of State, who co-chairs the taskforce, to make it work? What is the No. 1 thing that you want to make sure is uppermost in people’s minds as they move forward with the taskforce?
Baroness Amos: I will say one thing, but I have three little subdivisions.
Chair: That’s fine; I expect that. That’s why I limited it to one thing: because if I gave you three, you would have 10.
Baroness Amos: As I said, our recommendations interconnect. They are system-focused, but we did take a families-first approach in our investigation. All the work we did folded into our thinking about those recommendations, so the first thing I would say to the Secretary of State and the taskforce is: please accept all our recommendations, because implementation of all of them will make a significant difference.
The recommendations are long term. We have set timeframes. There are some urgent actions to be taken now, and I am pleased to see that what we said on triage, for example, has already been accepted, as has what we said on a maternity commissioner. I would also say: please don’t do a pick-and-mix here.
If I could say one other thing to the taskforce and the Secretary of State, it would be that listening to women and racism and discrimination are often seen as challenging cultural issues that it is very hard to address, so you do a little bit of training here and you do a little bit of training there, but this is safety-critical—the outcomes of doing that are worse. If you take a safety-critical approach, you embed these issues into how you think about developing your services and implementing your services and the way your staff conduct themselves as they carry out these services. So the safety-critical principle is absolutely vital.
Q5 Chair: What is the biggest risk to the taskforce and its job—other than people not doing all the recommendations at once, which is taken as read?
Baroness Amos: The biggest risk is that there is insufficient monitoring, that it all takes too long, that things fall off the end and that they are told that there are capacity and other issues that make this difficult. My personal view is that this is critical for maternity and neonatal services. I have to say I find it extremely difficult to get my head around how, in today’s world and looking ahead, we still have the scale of harm and bereavement that we do, and it is the reason why I agreed to chair this investigation. I cannot understand how in England in 2026, with the resources we have at our disposal, we have not managed to deal with this.
Chair: Thank you so much.
Q6 Alex McIntyre: Baroness Amos, Gloucestershire Royal hospital and the trust were included in your report. I should declare that I had a baby there a couple of years ago, so we were recently users of that service. One key theme in your report, which aligns with all the discussions that I have had with women in Gloucester, is how often they feel dismissed and not listened to. Ahead of this session, I asked women in my constituency to write in with their experiences so that I could 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 be taken to listen to the voices of women like those in my Gloucester constituency. What practical steps do we need to take to ensure that staff listen to women and are careful with their language? What training do we need to give and what action do we need to take? What should happen when women report being treated this way by healthcare professionals?
Baroness Amos: I will start and then hand over to Professor Sanders. We found medical misogyny across the system, and the recent women’s health strategy spoke about that as well. That is why listening to women is something that has come out not just from our findings but from findings across the piece.
In terms of what we need to do, that is why we say that the first step has to be embedding listening to women as a safety-critical element. That will mean that trust executives and the boards of trusts will treat it very differently. The data they collect, how and when they talk about it, how they look for trends and how they measure and monitor is very different if the issue is a safety-critical issue embedded in your performance as opposed to it just being an add-on. For the specifics you asked about, I will hand over to Professor Sanders.
Professor Sanders: First, we acknowledge that we too have heard far too many examples and experiences of completely unacceptable language and attitudes being shown to women and their families. Addressing that culture, and saying, “This is not acceptable: it is not acceptable to dismiss the concerns of women and families,” will take big change and take time, but we have to set those standards. That will be achieved not only through training, but through strong leadership.
One of our recommendations is that we need to improve leadership from board level to senior midwives and obstetricians to every single encounter in order to change the culture. We need to have strong leaders who are prepared to say, “That behaviour is not acceptable. You need to listen to women, and you need to respond to them. This is how: this is acceptable language, and this is language that we do not tolerate in this organisation.”
There are practical challenges in the capacity of lots of units. We saw many units that were working at very high capacity levels, and that produces an environment in which staff are stretched. This is not to justify the way that they behave, but when you are tired, have not had a break and are working long shifts, inevitably, you become less nice to people. That needs to be addressed through workforce measures.
Q7 Alex McIntyre: From a personal perspective, I had a fantastic experience. The midwives who looked after my wife, my little boy and our family were fantastic. The questions I am asking today are not targeting individuals, because lots of them work incredibly hard and are trying to do the right thing, but the system is obviously not working and is letting them down. I hear what you are saying about the capacity challenges.
Another constituent wrote in to say that, after birth, her daughter was transferred to the NICU, and the mother was transferred to a maternity unit without her husband or daughter and put on a full bay with other new mothers with their new babies. She was understandably distraught by the crying of the new babies, while her baby had been taken away to the NICU. When she asked to be moved, she was told by staff that she should go and buy some earplugs from Asda. Clearly there is an issue around attitudes, but what practical changes can we make to ensure that all mothers have the emotional support that they need in these intensely vulnerable moments?
Baroness Amos: We are very clear in our report that there is psychological trauma that women experience that needs to be addressed as a matter of urgency, and that is distinct from bereavement care.
A lot of the estates we saw were not fit for purpose, and what you describe is something that we came across time and again. We make a recommendation in the report that there should be 12-month, five-year and 10-year plans to improve the estates of maternity and neonatal care across the country. Obviously there will be financial implications to that, but it is urgent to review the estates, have those plans and then think about the costs attached.
We recommend that trauma-informed training and compassionate care be integrated into all the training that every single member of staff has. There are midwives and other staff who are specialists in certain kinds of care, but we do not think that that is enough. We think everybody needs to be trained, because everybody needs to be able to speak to women, birthing people and families with compassion, but with confidence that they are being compassionate. One concern that many have is that they do not know what to say or how to say it. It is both a cultural issue and a structural factor.
Q8 Alex McIntyre: Finally, your report touches on the poor availability of professional interpreters, which makes it harder for families to understand the care that they are receiving and to give informed consent. That is particularly important in Gloucester. It is a diverse city, and many people there have English as a second language. Sadly, the lack of interpretation services has led to the deaths of mothers in my constituency. Can you elaborate on what that looks like? In the report, you touched on community-based approaches that improve women’s ability to engage with maternity services. How could those be replicated nationally?
Baroness Amos: Again, part of this is safety-critical, because the outcomes are worse. It is also about how trusts engage not only with families, but with communities and the organisations that represent those communities. We heard about terrible examples in which family members or staff members were called upon to interpret. Some trusts are looking at different kinds of model, some of which involve online interpretation, for example. We saw one or two trusts that have developed robust community partnerships to assist. There are some very good examples out there that can be shared. This is an area in which it is important that trusts do not keep their good practice to themselves, but find ways to share it nationally.
Q9 Danny Beales: Good morning. Your review says that the CQC lacks credibility. Looking at some of the evidence, it is not a surprise. I am looking specifically at the Ockenden review of Nottingham: issues with reporting and serious incident regulatory inspections were first identified in 2007, but it took 13 years for the CQC to identify serious and persistent concerns and a further five years for it to bring charges. Why is it taking the CQC so long to act in these cases?
Baroness Amos: I have to say to the Committee that the issue of regulation and the CQC was raised by many families at the outset. They wanted us to conduct a more in-depth review of the CQC, which we were unable to do, but I did write to the Secretary of State at the time to make their views clear. What we found was significant regional variation in the way that the CQC operates, and a lack of clear standards. Standards change regionally. Indeed, when we talked to some trusts, they said that what they were being judged against would change even as they were being investigated. We found insufficient expertise within the CQC to judge what was happening in maternity services.
Q10 Danny Beales: Do you think that the move to more generalist inspections and more generalist staff affected that?
Baroness Amos: Yes, absolutely. Our view is that you need to have expertise within the CQC to handle this. In one trust, the CQC identified seven significant safety failures, including women leaving triage without assessment, and it assessed that trust as “good”.
Q11 Danny Beales: So it is possible that serious failings are identified, and yet a trust still gets a good rating.
Baroness Amos: That is what we saw through our investigation, and we feel very strongly that the CQC cannot provide assurance on quality and safety in a consistent way.
Q12 Danny Beales: Do you think that that should change?
Baroness Amos: 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. If you cannot trust what the regulator is telling you, you are not going to end up with a service that has better quality and is safer for women and families.
Q13 Danny Beales: Do you think that it is possible to reform and improve the CQC, or is there a fundamental issue with taking a general regulating approach but also having responsibility to check for safety and come in when there are more serious issues? Is it possible to do both?
Baroness Amos: I think it is possible to reform the CQC. It is going through leadership changes at the moment; it had a review by Penny Dash, which identified a number of issues that the CQC needs to address. Our strong view as an investigation team is that within the CQC you need a specialist function that does the reviews of maternity and neonatal care, with investigators who have the expertise required.
Q14 Danny Beales: Are these unique issues to maternity and neonatal services, where you would want a standalone inspection? We have had the Bristol baby scandal, with paediatric cardiology and very serious historic cases; I am not necessarily saying that that is continuing, but there have been other areas of care where there have been serious and persistent failures of safety. Do you think that it is unique to maternity and neonatal, or are there likely to be broader improvements to the CQC?
Baroness Amos: We had a discussion about this, as an investigation team. We think that there are some specific areas of maternity and neonatal care that are unique. 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 the health service more generally.
Dr Ekechi: It is a very important question. Ultimately, when assessors are coming in, the parameters within which they assess any service, often having understanding and previous experience and having worked in the system, allow a critical eye and understanding of what is causing those pressures, which means that they are able to provide a standardised assessment. Particularly in maternity and neonatal care, having assessors who have understanding and expertise in that area is imperative.
Q15 Danny Beales: Let us turn briefly to another issue on the theme of specialisms. Your review was tasked with looking at neonatal and maternity services. There has been some criticism that it has not looked at neonatal care services specifically, but only generally in the context of maternity. They are specific disciplines. For example, the neonatal charity Bliss has charged that some of the recommendations are perhaps too influenced by maternity thinking. Do you recognise that concern? What is your response to it?
Professor Sanders: Of course, we appreciate their concern. I would like to reassure them that the neonatal voice was very strong in this investigation. There were a similar number of neonatal consultants involved as expert advisers. Right through, at every single point, we heard from many parents who had had babies on the neonatal unit, and the public survey had many responses from parents who had experienced neonatal care. There was certainly no diminishing of the importance of neonatal care and that interface with maternity.
What we did often find was that neonatal services were not coming under the same criticism as maternity services. If the recommendations are more reflective of maternity services, that is reflective of the evidence that we gathered and the evidence that we heard from parents and from staff. Certainly, the staff survey reflected quite strongly that in neonatal services, issues with time pressures and resources were not as great as those that maternity services were experiencing. That is not to say that neonatal services do not have their pressures and their challenges, but they are not experiencing them at the same level as the rest of the maternity services.
Q16 Ben Coleman: 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. What immediate changes do you think that will make to the experience of women and birthing people? What resources and what backing from the Government will the commissioner need to have so that they are not just shunted off into a siding?
Baroness Amos: It will not be immediate, because our recommendation is that this be on a statutory footing. We have recommended that an amendment be made to the current Health Bill to make sure that it happens. Even with that, it would not happen until the end of the year, and then you would have to appoint someone.
The difference that it would make is about oversight and driving change. It would be independent of Government, reporting annually to Parliament, reporting annually to families and reporting twice a year to this Committee, so that it is possible to see what is happening with implementation, where the gaps are, where the challenges are and what is needed to continue to drive change.
It is an oversight role. We looked at the models of the Victims’ Commissioner and the Children’s Commissioner, for example. We did not make any kind of recommendation as to what the support should look like. That is something for the taskforce and the Department to think about.
Ben Coleman: About what support for the commissioner should look like?
Baroness Amos: Yes, the support that the commissioner should have; I thought that was the second part of your question.
Although we looked at the models, we did not have a recommendation as to how many support staff they should have, or anything like that. We were more concerned about the effectiveness of the role, working with leadership across the NHS and the taskforce, while having an independent oversight role so that the implementation does not slip back.
Q17 Ben Coleman: What sort of powers would this new person have to drive change?
Baroness Amos: The powers would partly be in terms of their statutory reporting to Parliament and to this Committee. The system has to give the data, 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.
Q18 Ben Coleman: That is helpful. I am thinking of the report that we did on black maternal health, in which we identified that there was a paucity of appropriate data to drive change. Could the commissioner demand that that data be produced?
Baroness Amos: Yes, I anticipate that the commissioner would do that if it were something absolutely vital, as we have said it is, because we think it is important to drive the system. Data is crucial to driving the system. The commissioner would have responsibility to say to the system, “This data has got to be produced—how are you going to do it?”
Q19 Ben Coleman: On the timing of the commissioner, I think you said that we are not likely to get them in place until the end of the year.
Baroness Amos: The Department is hoping that the Bill will have gone through Parliament by the end of the year.
Ben Coleman: The end of the actual year?
Baroness Amos: Yes.
Ben Coleman: And then we would have to recruit, so we are talking about a few months after that.
Baroness Amos: Yes.
Q20 Ben Coleman: The Secretary of State talked about a six-month plan to implement your report. The person who is going to become the commissioner would have no say in shaping that plan, because if the plan is going to be produced by Christmas, they will come in several months after it has been produced to implement it, so there is going to be a hiatus. Is that right?
Baroness Amos: The Secretary of State is chairing the taskforce, and the role of the taskforce 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 six months from now, there will be an action plan. As you say, the commissioner would not have a role in shaping that action plan, but that was always the role of the taskforce.
We recommend that the commissioner co-chairs the taskforce with the Secretary of State, because we see that independent oversight as important—independent of Government, and independent of the Department. 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.
Q21 Ben Coleman: Finally, you recommended that a modern service framework for maternity and neonatal services be set up within 12 months. To be honest, our Committee is unsure about how these frameworks will drive change. Are you confident that it will be an effective mechanism for improving maternity and neonatal services? If so, why?
Baroness Amos: Because these are, as the Committee knows, part of the 10-year plan, and this is the thing that will set the national standards for maternal and neonatal care. It is an odd name, “modern service framework”, but as an investigation we have sought to make sure that we are not reinventing the wheel and that we are working as much as we can with what is already happening that is good and positive, so that we are not adding recommendation on recommendation, as we have seen previously; you will have seen that we did a review of the over 700 recommendations that already exist in maternal and neonatal care. That is the thing that will drive the setting of the standards, against which we will then monitor what is happening in maternity and neonatal care.
Q22 Ben Coleman: How would the commissioner be involved in that?
Baroness Amos: You then have the standards against which you are monitoring. Part of the commissioner’s role, in terms of oversight, is helping the system to drive the implementation and identifying where there is backsliding, for example, where additional resources are needed or where there are gaps in implementation. It is about driving implementation forward.
Q23 Dr Cooper: I want to pick up on something that my colleague asked earlier about the scale of the issue and how it relates to the wider hospital system. Do you think that the maternity issues you have identified, by and large, are reflected in the hospitals in which they sit? To look at it another way, is it possible to find an exemplary maternity unit in a failing hospital?
Baroness Amos: I will let Dr Ekechi answer that one.
Dr Ekechi: That is a brilliant question. Personally, I work in an outstanding unit within a trust, where some of its services are outstanding, some of its services are good, and some of its services have challenges. When we talk about leadership, we mean the leadership at the top, so that is at trust level. What we found when we visited the 12 units was that where there was poor leadership, maternity services were often struggling. Conversely, where there was strong leadership that understood and had buy-in into maternity services, there were strong maternity services.
From my point of view, it is always interesting to look at services that are outstanding and understand why. Are they outstanding because the maternity system nationally allows that, or are they outstanding in spite of it? We found that there was this inconsistency in maternity care that is delivered across the country. That means that outstanding services occur in spite of the system.
Our recommendation is therefore to standardise high-quality maternity and neonatal care for everybody, every single time. Part of that is strengthening poor leadership all the way, from the service delivery leaders all the way to trust leadership, such that we can then see improvement in our maternity services.
Dr Cooper: That is really interesting.
Baroness Amos: One of the things we say in our report is that you need a national framework that helps trusts to implement, and we do not have that at the moment. If you are a trust and you have had an investigation, you get handed a whole set of recommendations. They are not necessarily shared nationally, and you do not necessarily get support to help you to implement them. That national repository is also important.
Q24 Dr Cooper: Are there any areas you would have liked to have covered in greater detail in your review, but were not able to? You said you saw a lot of things in a very short space of time. Are there areas that you would have liked to have looked at in more detail?
Baroness Amos: There is disappointment—for example, from a number of campaigning groups around specialised medical conditions—that we were not able to go into some areas in more detail. The whole area of maternal mental health needs urgent attention, and we have recommended to the taskforce that it looks at it.
There are also wider inequalities. Our report talks about racism and equality, and we are very strong on issues around racism and discrimination. We talked to representatives of a lot of organisations, including refugee organisations and Roma, Traveller, Muslim, Jewish and LGBTQ+ communities. There is so much in the area of inequality that needs to be addressed. That urgently needs to be tackled.
Linked to that is deprivation more generally. 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, as well as what happens even before a woman or birthing person becomes pregnant. We were unable to go into the level of detail that we would have liked, but all these things have a huge impact on what is happening in maternal and neonatal care.
Q25 Dr Cooper: You obviously talked to a wide range of groups, both public stakeholders and hospital trusts. What has been the reaction to your report, both from the groups you talked to and from some of the groups you did not talk to?
Baroness Amos: The reaction has been mixed, and we anticipated that when we started. For example, a group of families who spoke to me right at the beginning said, “We don’t think your report is going to deliver anything that we are looking for, because what we want is a statutory public inquiry.” They were very open and honest about that from the outset. There are campaigning and advocacy organisations that hoped we would go into more detail on some of the issues that they are concerned about, and we were not able to do that.
There has been criticism of the report with respect to what we said about a normal birth ideology. We did not want to dismiss the concerns of families who shared personal experiences of the findings from previous investigations, but in our investigation we were unable to find evidence of a national prevalence of normal birth ideology. We did not say that it did not exist, but we were not able to find the evidence of that, despite a specific question in the call for evidence and despite all the interviews we did both with people in the workforce and with families. I know that that was a criticism.
There has 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, there is not enough in our report that speaks to that experience. There has been quite a lot of that criticism.
Q26 Dr Cooper: You have talked a bit about your response to some of that criticism. Do you accept any of the criticism? No review is perfect. Have you had time to reflect on some of that criticism and on how you would perhaps think slightly differently based on the response?
Baroness Amos: Yes, we have reflected on that criticism. I think it is absolutely fair to say that we have not recommended a statutory public inquiry. The view of the investigation from the outset has been that that is for the Secretary of State and the Government, not us, to determine. Within the context of our terms of reference and what we were able to look at, in terms of normal birth ideology, what we have said in our report reflects the evidence that we saw and heard. It is a nuanced position; I absolutely accept that. I totally understand that if that has been your experience, the fact that we as an investigation team were not able to go further than we did, would have been a significant disappointment.
Q27 Dr Cooper: Do you support the calls for a public inquiry?
Baroness Amos: I have a personal view; I do not speak for the investigation. The families that have spoken to me have specifically talked about issues around accountability that I think our report, if implemented, will help to address. I have talked about the importance of individuals being compelled to give evidence. I think some of that will be addressed through the new Hillsborough law. I do not support those calls, but that is my personal view and I have not been through the traumatic and difficult experiences that those families have, so in many ways my view does not count.
Q28 Dr Cooper: Finally, I want to ask about the interplay, the overlap and the tension between your review and the reviews that Donna Ockenden is undertaking. We will hear from Ms Ockenden next, but I represent a constituency in Sussex and there will be an Ockenden review in Sussex. I speak to University Hospitals Sussex very regularly. It has now had your review and over 100 recommendations, both from your review and from looking at the Nottingham report. Do you think that those reviews are complementary? Do you think that for trusts such as mine in Sussex—where we have an awful lot of pressure and there is an awful lot of other stuff going on—having over 100 recommendations from those reports could be, in itself, problematic, or that the recommendations are complementary and will allow the Sussex families to get the review that they have requested and allow the trust to move forward with the maternity units, where the staff are clearly working very hard? How do you feel about both those reviews?
Baroness Amos: There is a huge overlap in terms of the issues identified by the different reviews. In fact, one thing that many people have said to us is, “But you haven’t said anything different.” I do not actually accept that, because I think the points that we make around safety-critical issues and so on and the national scope of what we did, looking at systems, is very different from case reviews in individual trusts. But there is a huge amount of commonality in terms of what all those reviews have found.
In our review of previous recommendations, we very much did not want to add lots of recommendations on top of that. We have said that the recommendations need to be looked at nationally and need to be prioritised. You cannot have 700 recommendations and trusts not knowing what is more important than what and where the resources are to do it, so there has to be national oversight of it. I hope that the action plan that comes out of the taskforce in December will have a degree of prioritisation in it.
Q29 Paulette Hamilton: Good morning, Baroness Amos and other panel members. I will start by pressing a little further into this normal birth ideology—Beccy covered the first bit of that quite well. Dr Bill Kirkup stood down from his role as an expert adviser as he disagreed with the principles of the findings, even going so far as to say to the BBC that you “listened to the wrong voices”. Ms Ockenden told The Standard that women were being denied caesarean sections, with tragic outcomes, and that it is a “national issue”. Could you tell us a little more about that? When we did our review, we heard things like that, but it has not come out in your report.
Baroness Amos: It is important for the Committee to understand that although Bill Kirkup was one of the expert advisers on our panel, he did not participate in our panels with families in any of the trusts, and so did not hear the evidence that we heard from those families. In our evidence, we were unable to find a national prevalence of normal birth ideology. We found other things; for example, a challenge with escalation when things were not going right. Perhaps you could say a bit more about this, Professor Sanders.
Professor Sanders: The first thing to say is that, yes, we heard from women and families who did not receive medical interventions when they were clearly warranted, and we acknowledge the psychological and physical harm and trauma that that caused. But we did not hear that that was driven by ideology. It is well-known in maternity services that a whole chain of events leads to intervention: first, recognition that you have a problem, then escalation to the right people, and then the right interventions. If that chain breaks down at any point, the women will not receive the care that she should do. We certainly heard examples of that.
What we need to explore further, and are perhaps not exploring enough, is why those issues are happening. We certainly heard about issues with staff pressures and capacity, where midwives were very aware that women needed reviews—particularly in triage, for example—but because medical staff were not immediately available or would not be available for some time, there were delays to treatments. We are also aware of there being a lack of senior staff who are often present in our units out of hours. We make a recommendation for a complete review of workforce planning and a new workforce planning tool—
Q30 Paulette Hamilton: We will talk more about workforce planning later on. I just want to get your view on why there was this absolute division between people like Dr Bill Kirkup and other members of your panel.
Professor Sanders: We were very conscious when we went out to gather evidence that we would be challenged and asked about this issue. In the evidence that we gathered from the site visits, talking to many staff, the staff survey, the public responses and seeing the services, we did not see evidence of women being deprived of medical interventions due to an ideology. The staff were very clear that this is not happening. Our report needed to reflect the evidence that we gathered, which I believe we have done with integrity and honesty. It is not our position to put in the report something that we did not find.
Baroness Amos: To add one other thing, women and families also told us the opposite: that they were being encouraged down the route of medical intervention when what they actually wanted was a vaginal birth. To really reinforce the point made by Professor Sanders, it was our view in the investigation that it was not in the interests of women and families to make claims in our report that we could not substantiate.
Dr Ekechi: If I could make one final point, the key thing in all of this is women being listened to. These discussions and debates are important, but we must always remember that women are at the centre. If a woman wants to have a vaginal birth, we must support that, and if a woman wants to have a medicalised birth, the system needs to support that. We found that the issues were—
Q31 Paulette Hamilton: Can I disagree with you slightly? I am a nurse by trade, and my background is health. Sometimes, I may want something, but it may not lead to the best outcome for me and my baby, if I am carrying one. I may be determined about the direction I want to go in, but it may not be the best direction. We absolutely support patient choice, but we are the medical professionals, and sometimes it may not work for them.
Dr Ekechi: Of course. As an obstetrician, the final part of that sentence was, “with the safety of the mother and the baby at the core.” It is about the system and the mother being able to have a conversation and support that journey. Part of what we found is that this is where the listening has been failing. As obstetricians and midwives, if we find that there is a deviation away from that path, we must be able to have that conversation in a way that is trauma-informed, sensitive and empathetic, and the capacity in the system needs to be there so that we can maintain safety.
Q32 Paulette Hamilton: I am going to stop you there and move on to another question, but I will also say that the biggest issue we found from our report is that people are not being listened to. This panel has talked about a birth ideology. Someone might feel that they have not been listened to and that a midwife or obstetrician has an idea of a direction of travel. Does the panel feel that sometimes, if that obstetrician or midwife has an idea around the birth ideology, although they do not necessarily say anything, that is the direction they take the mother in, and it sometimes leads to the conclusions found in Nottingham, Morecambe Bay, Oxford and other places?
Mothers do not totally understand. Mothers want to be heard. They are sane, but because of how the system is—Baroness Amos explained this really well earlier when she talked about needing a framework—people sometimes do not know how to measure it, because there is nothing to measure it against. Do you agree that that is an issue? It is just a yes or a no, really.
Dr Ekechi: No, because our evidence did not show that at all.
Q33 Paulette Hamilton: Fair enough. That is a good answer—or a final answer.
Baroness Amos, my second-to-last question is about the “Black Maternal Health” report. Thank you for speaking to me before you started this. The report was published last September, and one of our key items was about cultural competency training. We really wanted the Royal College of Midwives, the NMC and the NHS to look at this training, but the Government did not commit to it when we made the recommendation. In your view, following the publication of these reviews, is there any appetite in the system—that is the first part—and what is the risk of not doing it now?
Baroness Amos: Thank you for the question. Training is absolutely important. We recommend a review of anti-racism training, because there is something about the quality and impact of it that we really need to address. Asking people to do an hour every couple of weeks online is just not going to deliver the kind of cultural change that is looked for. We recommend something even before that, because what we found in some of the trusts was just an inability to even start a conversation about the impact of racism and discrimination in their organisation. If you are not actively having those conversations, even with the training, the cultural change that you are looking for will not happen. Yes, I think there is an urgent need for cultural competency training, but it has to be the right kind of training, and it has to have been tested. We should not be just rolling out training that is not having the desired impact.
Q34 Paulette Hamilton: Do you believe that the training should be developed in the long term, after you have the commissioner you have talked about, or should we be doing this urgently now to get it in place even before the reference group and the taskforce come back to us?
Baroness Amos: Absolutely, we could be doing this now. There is work that is already ongoing, which the NHS Race and Health Observatory is doing, that speaks to some of this. 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 will always be an issue for trusts and NHS organisations, so let’s get on with it now.
Paulette Hamilton: Thank you, Baroness Amos.
Q35 Josh Fenton-Glynn: I will talk about the workforce in a second, but it strikes me that fundamental to a lot of what has been said and to the report is a breakdown of the doctor-patient and midwife-patient relationship. That tallies with what people I know say about birth plans not being looked at and so forth. Do you think that that is the case, and do we need a fundamental cultural reset, or do you think it is just a result of the pressures on midwifery and obstetrics?
Baroness Amos: We found huge tensions in that relationship in some places, but also in other relationships within trusts. The important thing is to be working as a multidisciplinary team, which we talk about.
Josh Fenton-Glynn: That is not the same as the doctor-patient relationship; that is the obstetrics-midwifery relationship, which I will come on to in a second.
Professor Sanders: In terms of the workforce and those relationships, we saw very good examples. We saw staff—midwives, obstetricians, maternity care support workers and anaesthetists right across the board—working really hard to build those meaningful relationships and have those meaningful conversations. What we heard time and again was that, due to those staff pressures, antenatal check-ups particularly are just not long enough to have those meaningful conversations and build those relationships. Someone has already mentioned interpreters; in primary care, there is a standard that, when you are working with an interpreter, you have double the length of the appointment. That has never been applied to maternity services, and that cannot help with developing those relationships.
Q36 Josh Fenton-Glynn: Do midwives need to return to case holding so that they have a better relationship with their patients?
Professor Sanders: On the return to case holding, we strongly recommend putting your efforts into strong continuity during the antenatal period and the post-natal period when it comes to organisation, particularly around midwives. You should be able to organise it so that a midwife does the same clinic on the same day every week—it should not be that difficult—and then sees the women back at home. We are not recommending intrapartum continuity. That was attempted, with great efforts, after “Better Births” in 2016.
Q37 Josh Fenton-Glynn: I will move on to the questions that I am supposed to be asking—that just struck me as one of the things going on. You have talked about the need for Government action to ensure clinical capacity and escalation pathways, including at weekends. Is that possible, given the other pressures on maternity at the moment?
Dr Ekechi: What we found, again, was huge variation across the country in terms of seniority of cover, particularly out of hours. In some places, it is about the availability of senior—and senior can mean very senior residents or consultants. Often, where you had patchy coverage, particularly out of hours, when you looked at the workforce, these trusts had difficulty staffing their rotas, as a minimum. Baroness Amos spoke to that in terms of the geographical challenges that many of the trusts experienced, in terms of not just their demographics but recruitment at midwifery level and doctor level, and also in the allied specialties that are required.
Q38 Josh Fenton-Glynn: Very quickly, you talked about the NHS workforce plan, and it is probably too late for us to influence that. But given the cost of training for an individual, do you think that midwifery training is currently an appealing thing for a young person to go into, particularly given the pressures?
Dr Ekechi: I will hand over to my colleague.
Professor Sanders: Sorry, I didn’t hear the question.
Josh Fenton-Glynn: You talked about the need for more people to come through. Given the cost of training for individuals and the pressures in the system, do you think that a career in midwifery is currently appealing?
Professor Sanders: I would say we still have some of the best midwifery education in the world, which is regulated by the NMC and delivered through very high-calibre training courses in HEIs and other places. There is no shortage of people wanting to be midwives, despite all the publicity and all the pressures they are well aware they will be entering into.
You are probably asking the wrong person, because I am from Wales, where, if you train for an NHS position, the Government pick up your tuition fees. It is not in the report, but I would strongly support that. We need to be supporting our students and looking at all the variety of ways to train individuals.
Q39 Josh Fenton-Glynn: Is retention the problem, rather than recruitment?
Professor Sanders: Retention is absolutely a problem. We need to make changes. The retirement age for NHS staff coming in now is 67; we need to restructure careers so that we can give them longevity. We need good preceptorship programmes to support our more junior staff. There is a peculiar issue with—
Q40 Josh Fenton-Glynn: So what do we need to see in the upcoming workforce plan?
Professor Sanders: In the workforce plan, we particularly need to look at careers for midwives, so that they can progress into specialist roles but retain a clinical, hands-on component. Maternity is a safety-critical service that runs 24 hours a day, seven days a week, but at the moment many of our senior midwives finish work at 5 o’clock. Units are being staffed out of hours by relatively junior staff, who are excellent but need support. We need to restructure those careers to support our junior staff and give postgraduate training to midwives, which is currently more or less completely lacking.
Q41 Josh Fenton-Glynn: Baroness Amos’s report notes that 67% of midwives are experiencing burnout and 65% of doctors are at risk of burnout. I should declare an interest: I used to work for the GMC and work on the national training survey. Last year, it found that 63% of trainee doctors in obstetrics and gynaecology had a heavy or very heavy workload, compared with 42% across the rest. What can be done to support our trainee doctors and midwives, just to make the training pathways safer?
Baroness Amos: In terms of that general support, one thing we say in our report is that it is important to look at the range of our expectations of our doctors and midwives to make sure that there is sufficient time for them to do the things we want them to do—particularly around the areas of listening and tackling racism, discrimination and so on—and that sufficient time is built into rotas and appointments. What you have at the moment is a system where everyone is expected to meet standards and to have long conversations in very short periods of time, which puts pressures on the women and families and on the doctors and midwives.
Q42 Josh Fenton-Glynn: So where I started is where we should end: the pressure on midwives and doctors is leading to a breakdown in the doctor-patient relationship, which brings up safety concerns. Is that correct?
Baroness Amos: Yes, in some instances.
Chair: I am sorry to say that we have to end this first panel. I am grateful for your time.
Witness: Donna Ockenden.
Q43 Chair: Welcome, Donna Ockenden. It is such a pleasure to have you with us; thank you very much. I am just going to get cracking.
Your report was heartbreaking to read. I cannot even imagine what you went through, but more especially what the families will have gone through in its preparation. What were some of the challenges that you faced in pulling it together, and what choice things are you very keen about? It was a massive report, talking to thousands of families, but what does it boil down to in the end for you?
Donna Ockenden: It boils down to two very similar things: lack of listening to women and families, but also lack of listening to staff, and that is where Nottingham was different from Shrewsbury. Some of you may have seen my presentation to the taskforce last week, where we showed that what staff on the ground were saying was almost identical to what women and families were saying.
Secondly, it is really important to say that we all have to be born and, at some point, we all die. 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. That is now, I hope, leading to national work.
The pressure that ordinary staff on the ground are under on a daily basis is really important as well. We spoke to more than 830 ordinary staff on the ground—midwives, obstetricians, anaesthetists and so on. There were disappointing numbers of former senior leaders who came forward. But those staff that did come forward—really brave midwives, obstetricians, support workers and so on—described years upon years of raising concerns right up to board level and being disregarded in the same way that women were.
Q44 Chair: Of course, several police investigations are under way. We will have to be very careful in our questioning that we do not stray over that. You will have seen an intervention by the former Secretary of State, Wes Streeting. He wrote to us to say that we should be using our privilege to name and shame, but also calling in front of us, some of those executives who refused to give you evidence. Do you think that is a good idea and something we should look at? Perhaps even more importantly, what was missing from your report as a result of them not giving you evidence? What did you hope to hear from them that you feel might not have been reflected in your work?
Donna Ockenden: I think there is a difference between staff on the ground, who are living the reality of, in most cases, trying to deliver the best care they can, and then executive leaders. I would stress that these are recent, former executive leaders, and I want to be really clear that all the executives at the trust came forward as requested. Clearly, there is going to be a difference in focus, because a recent, former executive leader is going to have been responsible for the leadership of the trust, hearing staff concerns and hearing concerns from women and families. So there would have been an extra strand of information that we would have wished to get from those former leaders, but that we did not.
I am grateful, Chair, that you mentioned the police investigation, so I do not think that I should comment any further on who may or may not have come forward, because I am still awaiting police advice on that.
Q45 Chair: Understood. We will leave that alone.
You will have seen that Jim Mackey put out a 10-point urgent maternity plan following the publication of your review and then the Amos review, which was more or less co-concurrent. Did you speak to him about the plan? Do you think the plan is the right one? What involvement did you have?
Donna Ockenden: I was not told about the plan until it was out there on Radio 4 and so on.
Q46 Chair: Now that you have seen it, do you like it? Is it along the right lines?
Donna Ockenden: What I would say, and I have said this very clearly since my report was published, is that we do not have the luxury of time now. The current conversation, as I understand it, is that the taskforce is going to take up to six months for an action plan. What I would say, having heard from thousands—and I mean thousands—of families and colleagues on the ground across all the professions since we published on 24 June, is that we know what we need to do to improve on perinatal safety. So I did urge the Government to move at pace. We set out a really comprehensive suite of immediate and essential actions—I do not use the word “recommendations”, by the way—agreed by families, royal colleges and so on back in 2022. There was partial introduction, even though the then Secretary of State—
Q47 Chair: What has happened? Let us be really frank about it. Why has that not just been implemented wholesale?
Donna Ockenden: My honest belief is that, had we maintained the Secretary of State at the time, the right hon. Sajid Javid MP, I think we would have got there, because he took an enormous amount of time to understand what my team and I were saying. We will all remember that there was a lot of churn and change at the top. I think I am now working with or for my 12th Secretary of State for Health since 2016, which is obviously of concern. Whenever there is that change, there is a risk that we lose our way, even though we know what our way needs to be.
Chair: So the chopping and changing—
Donna Ockenden: Doesn’t help.
Chair: It doesn’t help. I will pass over to Dr Beccy Cooper.
Q48 Dr Cooper: As I said to Baroness Amos, I represent Worthing in Sussex, and you are due to commence a review in October with the families in Sussex. University Hospitals Sussex has obviously taken on the recommendations from the Amos review and has looked at your Nottingham review. There are over 100 recommendations from both. It is on a 100-day sprint for the Amos review. What is your review going to bring to Sussex? You said you have spoken to so many people and are seeing similar patterns—horrific, tragic patterns. For the families and teams in Sussex, and the other reviews that are going to happen as well, can you talk about the additionality of those reviews?
Donna Ockenden: An Ockenden review—there are hundreds of people behind me in my team, by the way—has two purposes. First of all, it is to find answers for families that they may not yet have had, but equally something we have done in the last three years in Nottingham is talk to huge numbers of staff. I can tell you that University Hospitals Sussex staff are already coming forward in large numbers to say, “Can we talk to you and your team, Donna?”
In terms of the last three years, and this will be rolled out in Sussex, we did not just hand Nottingham a great big purple report. We had bi-monthly—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 that they needed to do, and then we looked at their evidence on an ongoing basis. I can say with confidence that Nottingham has put in place a lot of the learning throughout the process; it is not about waiting for three years for Ockenden to finish her work. As you are a local MP, I am sure we will be in touch on a regular basis. I want to reassure Sussex and Leeds MPs about the way we do things.
Q49 Dr Cooper: I asked Baroness Amos about recommendations in her review complementing the recommendations that will doubtlessly come out of your Sussex and Leeds review and previous reviews. Do you see large areas of overlap and complementing recommendations for the trusts and for letting families hear about improvements?
Donna Ockenden: Yes. Having been in and around perinatal services since 1989, which is a very long time, I think that we often know what we need to do, but we simply do not get on and do it. That is one of the issues that we face at the moment—albeit I still think it is absolutely vital that staff on the ground get to have their views heard. We will work very hard with UHS staff on the ground. Families deserve answers. There is something about the system that means that parents are waiting years for answers and staff voices are still silenced. We have to get that right.
Q50 Chair: Baroness Amos said earlier that the taskforce will have the job of prioritising what they go after first, second and third. Paulette has just left the room, but she and I sit on one of the expert reference groups that will feed into the taskforce. What should be feeding into the taskforce as the top priority that we should be going after? We need to do it all—that was made clear, and I am sure you would agree—but what is the top priority in your area?
Donna Ockenden: There are priorities that are interlinked. First, listening to women, families and staff on the ground is one. That is absolutely vital and the golden thread, but we will not achieve that until we have a comprehensive perinatal workforce tool—I am a midwife and a nurse, but it is not about midwifery and nursing—that tells us what we need. We know that we have gaps across many rotas, including obstetric rotas, and we have vacancies in midwifery and neonatal units that are under significant pressure.
I do not believe that we have ever had a perinatal workforce tool. That needs to be funded, so you might say to me, “Where’s the money?” We are already spending vast of money on compensation for harm when none of the money in the world will bring back what families have lost or compensate staff for the moral injury that they suffer on a daily basis. I have heard from hundreds of doctors and midwives—hundreds—in the last four weeks saying, “We don’t know how much longer we can take this.” I have heard obstetricians saying, “I am not sure now, Don, that I can actually complete my training,” and midwives saying, “Is tomorrow going to be the day I hang up my uniform for the last time?” Time is not on our side, Chair.
Q51 Jen Craft: Good morning. I would like to focus on accountability, because I understand that your review highlighted the impact of poor organisational culture and leadership. What does accountability in this space mean to you?
Donna Ockenden: It is about truth-telling, hearing and taking the action that one is in public office for. There has to be a sense of responsibility. If we take the aspect of after-death care in Nottingham, there has to be accountability for what happened to those families. It is myriad things brought together under one umbrella.
Q52 Jen Craft: Does the lack of accountability in organisational structures in itself lead to some of the failings that we have seen?
Donna Ockenden: I think it has. For example—this is in the report—50 midwives and maternity staff wrote to the chairman of the board in 2018, and they did not get a response, so they tried again in 2019. They were so worried that they told the board that babies would die in 2018, but nothing was done. In 2019, in Nottingham, an inquest got halted, which is really unusual. The coroner read out that letter to be supportive both of the families and of the staff on the ground. That is an absolute failure of accountability.
Q53 Jen Craft: We heard in the previous panel from, I think, Christine Ekechi on the question whether you can have outstanding maternity services in a poorly performing trust. I think the answer was that, if you can, it is despite the system, not because of it. It is about the leadership at trust level rather than necessarily within a maternity service itself. Would you echo that? Is it about addressing poor leadership at the very top of trusts, or looking more at where the maternity services operate?
Donna Ockenden: I think it is both. I know of some outstanding maternity units with outstanding leaders. Having been around as long as I have, I know of many outstanding board leaders, but if we take obstetrics and midwifery now, I know many brilliant consultant obstetricians and consultant neonatologists and they are saying to me, “We do not want these leadership positions.” I spoke to a doctor last week who said to me, “Maternity governance broke me. I had to walk away.” Leadership is there on the ward, on the day, interacting with women right up to board level and then commissioning level. There should be seamless leadership literally from ward to board.
Jen Craft: A clear line of sight through?
Donna Ockenden: Absolutely.
Q54 Jen Craft: Why are they refusing to take those kinds of leadership position? Why are they saying that they do not want them?
Donna Ockenden: The pressure. There are insufficient resources. To be clinical director of obstetrics or maternity governance, if you are very lucky, you may get one day of time, which is in no way sufficient. In some trusts, they are given half a day of time. These leadership positions are not respected. As I say, it breaks colleagues, which is really worrying.
Q55 Jen Craft: In your report, you said that it was of particular concern that many of the issues were already known and that there had been several attempts to flag them throughout the years. Is the current regulatory framework fit for purpose?
Donna Ockenden: That is a really good question. We have seen, throughout the duration of the Nottingham report, some improvement in the relationship between the main regulators, the General Medical Council, the Nursing and Midwifery Council and families, but that has been hard-won. It has been hard work, if I am honest. I am confident—I met with the GMC, NMC and CQC 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 am going to speak as I find, and it has been extremely hard work to get to this place. It has taken three years of concerns raised by families and by me. I think we are in the last chance saloon. We are going to push really hard to get this effective relationship between families and regulators for Sussex and Leeds. I am pretty confident that we can, but I will have my eye on it, believe me.
Q56 Jen Craft: Why do you think the regulators have not really performed in this space up until now?
Donna Ockenden: It is really interesting. If we take Nottingham as an example, because that is the place I know best and am most up to date with, there were lots of opportunities for regulators to understand. HM Coroner in Nottinghamshire is really active. There were lots of inquest verdicts where negligence was ruled and deep concerns about the care, yet the regulators were not aware of those cases. I know that HM Coroner invited the regulators on multiple occasions to attend inquests. There were significant lost opportunities.
Q57 Jen Craft: Is it how they operate? Is it because they are not taking a proactive approach or looking at the system as a whole, or is there something else going on?
Donna Ockenden: I think they have not, to date, but there have been some very honest conversations between families and regulators, and myself and regulators. I see that we have green shoots of recovery, but I will be keeping a very close eye on it for the duration of the Sussex and Leeds reviews.
Q58 Jen Craft: I am always interested in where the accountability lies in a healthcare system. For a constituency MP and service user, it is quite hard to see people who are often paid a lot of money seemingly fail upwards in their career progression within a system that fails and continues to fail. I do not want to go into the individual level because there is an ongoing police investigation, but it feels as if you are saying less that there are individual failures of leadership and more that the system itself is not set up to support those leadership roles to be effective. Is that right?
Donna Ockenden: It is both. 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. All of us in public service in the NHS, whether we are in a leadership role, the midwife on the ground or the obstetrician on the labour ward, are accountable, but I do not think that the system as it is currently set up supports staff to be always able to do the best they can and deliver things the way they want to.
Q59 Jen Craft: What would you change in that space?
Donna Ockenden: The key issue is that we need to look at why we are allowing so much maternity harm—we are talking billions of pounds—to happen in this country and why we are allowing so many staff to feel damaged by their everyday working life, and say, “The tide has now got to turn. It has to turn.”
Q60 Danny Beales: We have heard a lot from Baroness Amos’s review and your work about the failure to listen to women and families. The previous panel touched on what this means practically in consultation and conversations about birth choice and how it can be affected. I want to focus on what it means systematically because of time, though if you want to add anything about how to build that into decision making in clinical practice, we would be very happy to hear it. Do you have thoughts on how patient and family voice can be embedded more systematically within trusts, unit decision making and governance arrangements? Is that something you think needs to happen?
Donna Ockenden: Yes, absolutely. Among the thousands of families that we spoke to, there were countless illustrations of women, husbands and families not being listened to. That can be a time issue, without a doubt. Not having time to care is really important, and we have to be honest that it is a daily feature of life in perinatal care in this country. Again, it is about resetting the ship. We have heard that these things were happening in Morecambe Bay, East Kent and Shrewsbury. We still have not done enough to turn that ship around.
Q61 Danny Beales: Are families and parents often represented on trust boards or in their governance arrangements? In my experience, many of the governance boards tend to be older or retired people. Are there peer groups or family groups right from the top in governance arrangements of trusts or units? Are they embedded in peer-reviewing the unit for family-centred practice? As well as hearing the mother and family’s choice about their birth, is the voice of families and parents reflected right through how trusts are run?
Donna Ockenden: We had contact with families over a three-year period in Nottingham. As women and babies are now discharged so early from maternity care, sometimes it was up to me and my team say to the trust, “Are you not aware what has happened to Mrs Jones or Mrs Ali? Do you not know that she is at home struggling with the most appalling health problems?” We did make some differences. We had to set up an escalation pathway in Nottingham for families’ urgent care needs, whether it was brain-injured children or mothers needing colorectal support, that the trust was completely unaware of.
We have seen some real improvements in Nottingham in terms of engagement with the local communities. However, when I got to Nottingham late 2022, I said, “How do I meet with the Roma community? How do I meet with the Jewish community? How do I meet with the most disadvantaged women?” and got a blank face in response. I had to go across the city and the county and find those groups for myself, which I have done. I have reintroduced them to the trust, but they were not in the best place at the start of this review.
Q62 Danny Beales: Are there any systematic approaches that you have seen that work well? A trust board is probably worried about their A&E times and their bed occupancy rates, and they are under huge financial pressure. It sounds like quite a fundamental change is needed in the risks that they are looking at, who they are hearing, and how they are speaking to people to get their feedback.
Donna Ockenden: What I have found in my years and years of working with community groups, listening to women and listening to families is that the NHS almost needs to turn itself on its head. People say, “Well, women over there are hard to reach,” which they absolutely are not; if women and families are asked, they will give freely of their experience. They will engage and put huge effort in, but there is a tendency to say, “Over there—hard to reach.” That is not a phrase that I will use at all.
Q63 Danny Beales: Where people have turned it around and where they do listen, is there anything they specifically do? Is it making sure there is time on the board agenda? Is it having a representative for midwifery? Obviously, there is normally a chief nurse role, but is it having a specific midwifery voice at trust level? Is there anything that particularly works in hearing the staff and patient voice?
Donna Ockenden: I spent many years—more than I can count—as a chief midwife. The relationship between the chief nurse, the chief midwife and the medical director is absolutely vital. I have seen many settings where that works very well.
It is also about ensuring that the services on the ground are resourced. It is important how much we in the NHS expect women and families to do free of charge. Some of the Nottingham families have virtually worked full time supporting community engagement and making sure that they liaise with other families who often would not be heard. We are not resourcing that at all for those families.
Q64 Danny Beales: More resource and peer support should be a focus for us?
Donna Ockenden: Yes. It is very poorly resourced.
Q65 Andrew George: You said a moment ago that staff feel damaged by their everyday working lives. There is clearly a crisis in staffing levels across many of the settings that you have reviewed, including Nottingham more recently. I note that a recent Royal College of Midwives survey published last month showed 77%—more than three quarters—of those who responded did not feel that their team or unit was safely staffed. That is something for us all to worry about. Some 93% felt that staffing levels affected the quality of care they were able to provide for women and babies. That is extremely shocking, and presumably that is at the base of why circumstances such as those at Nottingham arise. How do we overcome that? How do we attract the right people into post and attract sufficient numbers of them to be able to support each other?
Donna Ockenden: There are a number of issues here. There is recruitment, but there has to be retention. I talk to midwives and doctors on a daily basis. If they are doing a 12-hour shift, they do not even have time to go to the loo.
The big issue is that we do not 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, and these are the number of midwives.” Until we do that, we do not even understand yet what we need. That cannot be tolerated any more.
Q66 Andrew George: Does that need to be mandated?
Donna Ockenden: It was an immediate and essential action from Ockenden, not a recommendation. It was something that we worked on with all the royal colleges—midwives, obstetricians, anaesthetists and so on. I am a midwife, but it was not about me being precious about midwifery. It was about saying that maternity is not an island and there is a big team of people who are required to deliver safe care. I do not think we have done enough towards that yet, but I am confident that the royal colleges were absolutely involved in the drafting and crafting of that immediate and essential action.
Q67 Andrew George: Is there now a mandated framework?
Donna Ockenden: Not as far as I know. I was at the taskforce that the ERG uses last week. I do not know what the outcome was from that, but I was really clear—
Chair: I think that the taskforce is meeting this week, so it feeds in.
Donna Ockenden: Right. I was really clear that we do not have six months to wait.
Q68 Andrew George: Is that in relation to the number of antenatal and post-natal beds? Are they sufficient in number? In many settings, it seems that often women are discharged in antenatal circumstances when perhaps that is unwise, simply because there are insufficient beds.
Donna Ockenden: Yes. I saw it in Nottingham, but what I hear from all my colleagues in Newcastle down to Cornwall is that, as one real doctor on shift last week said, “We are trying to deliver safe care with at least one hand tied behind our back,” because they have not got sufficient neonatal cots. The infrastructure was lovely in 1998 or whatever.
Maternity and perinatal estates are also of vital importance. I spoke to a doctor not very far from your constituency and he said to me, “I was doing emergency drills and I had to take my junior doctors out on the patio by the bereavement suite and hope that the suite wasn’t needed, because I did not have anywhere else to take my resident doctors to train them in emergency drills.” That was last week.
Q69 Andrew George: The report that you produced obviously had some shocking and extremely distressing cases. It is very difficult to say, but in how many cases would you say that that was driven not just by an attitude and a way of speaking to patients, but by the pressure of inadequate staffing levels?
Donna Ockenden: Inadequate staffing in Nottingham was well known by the board—and there have been multiple iterations of the board—going back at least to 2010. Staff were raising concerns going back to that time, and parents started whistleblowing in 2016. There were many years of inaction. However, we also need to be clear 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. Again, staff on one—
Q70 Andrew George: Are we talking at the clinical or leadership level?
Donna Ockenden: Within the division—it was both. “Infect” the unit is a very strong word. However, staff and families both said it without ever having talked to each other in the middle. I think that behaviours play an important part and poor behaviour that was tolerated definitely played an important part. It is important to say that staffing was a long-term and known board issue with no action.
Q71 Andrew George: In terms of the Government’s response and the proposal to invest £10.6 million into the recruitment of additional band 5 midwives, band 5s are paid at £31,000. Are you going to attract the right kind of people with the right capacity into that post with pay at that level?
Donna Ockenden: As I understand it, band 5 midwives are very newly qualified. I know from my experience in Nottingham that when one invests in large numbers of newly qualified midwives, you have to have the preceptorship support programme because they are very, very junior.
I have seen some good practice in that. After Shrewsbury, University College Hospital in London invested in what it called Ockenden-retention midwives—I checked recently and these posts are still in place—where very senior midwives are there literally to hold the hands of and support newly qualified midwives in the first year to 18 months of their career. I then hear from elsewhere in the country that midwives are put under quite a lot of pressure to get their band 6 competencies. I do not think that the good practice I have seen and heard of is by any means rolled out across the country.
Q72 Andrew George: In the past, to become a midwife you would become a registered nurse and then do your midwifery as a postgraduate. A lot of experienced midwives believe that being trained simply as a midwife and working in the more limited clinical perspective landscape has created less capable midwives, given the range of complexities that they may be presented with. In your experience, does that sound reasonable?
Donna Ockenden: I trained in the olden days: nurse first, midwife afterwards. I think there is room for both. I would very much like to see more registered nurses, perhaps with ITU or surgical experience, join midwifery. We need to look carefully at the training programme currently offered to qualified midwives as a stand-alone profession. They do not have that nursing background, but I think there is room for both.
Andrew George: Okay, thank you. I was looking for your facial response when the issue of Dr Kirkup and the Amos review came up, and the issue of natural birth ideology was under discussion.
Chair: That is someone else’s question.
Q73 Andrew George: If you don’t mind, may I ask this? Given your perspective across a number of inquiries, would you say there is an issue in relation to non-clinical groups campaigning for such things?
Donna Ockenden: In Nottingham, we used the phrase “normalisation of deviance”, where we found significant evidence that women who were no longer normal were being denied the care and treatment they needed. That is the phrase that we used—“normalisation of deviance”—and sadly there are lots of examples of that with tragic outcomes in Nottingham.
Q74 Gregory Stafford: You have read the Amos review and heard the evidence given today. There is clearly a lot of agreement between you and Baroness Amos in the review. But when The Standard approached you, you said, “I don’t see anything that we didn’t already know, that hasn’t already been spelled out very clearly.” Do you think the report adds anything significantly, and how do you see it playing out and interacting with your reports and reviews?
Donna Ockenden: Having spent decades in and around maternity care, this is now my second inquiry, and Sussex and Leeds will be my third and fourth inquiries. I think that what we have amassed over many years has been a vast amount of knowledge on maternity and neonatal care that we simply have not acted quickly enough on. If I had been shocked—I did read the Baroness Amos report from cover to cover, burning the midnight oil—I think probably I would not have been doing my job properly, because a lot of what was in there, as we have said, is very similar to Dr Kirkup’s previous work in East Kent and Morecambe Bay and in my Shrewsbury review. So, I think that is the issue.
Q75 Gregory Stafford: I pointed out that there were a number of areas of agreement in your reports. Were there specific areas where you felt the recommendations were not helpful, something you would not recommend or where you did have disagreements with Baroness Amos’s report?
Donna Ockenden: I mentioned the normalisation of deviance to your colleague. We definitely saw that in Shrewsbury, and we very definitely saw many women being denied the treatment that they needed, with tragic outcomes.
Q76 Gregory Stafford: Why do you think you were able to pick that up, but Baroness Amos—
Donna Ockenden: I cannot answer that question. I know what we did. We had interaction from 2,511 cases and we heard from so many staff on the ground who said, “We were under pressure to discharge: ‘Get them out the door.’” And then there were the appalling behaviours that you may have seen on a recent BBC programme. Extremely rude things were written on whiteboards in labour wards. Basically, there was this culture of “get them out the door”. There are many issues, but staff told us and families told us, and yes, we believe them.
Q77 Gregory Stafford: One recommendation that Baroness Amos made was about doctors working on site at weekends. You said that that would not make a difference—“absolutely not” was your phrase. Why were you so clear that it would not make a difference?
Donna Ockenden: Again, we heard from very many obstetricians in Nottingham, and my team heard from people in places ranging from Newcastle right down to Cornwall. These are doctors who will be on their labour wards today and on the weekend. And what all these colleagues and the hundreds of colleagues who have contacted me since are saying is, “We are spread so thinly on the ground. Where are these people going to come from?” I get midwives telling me this on a daily basis. Maybe it will be their day off tomorrow. They will wake up tomorrow morning—they are in these famous WhatsApp groups for when the unit is short-staffed and they say that day in, day out, managers are saying, “We know you have a day off today. Is there any chance you can come in?” or “You have 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.
Q78 Gregory Stafford: To drill down a bit more into the denial of caesarean sections, which you saw very clearly in your report, that may be down to clinical reasons or to ideological reasons. Your report suggests very clearly that it was ideological. If we as a Committee are trying to make recommendations, but we have on the one hand your investigations and reviews, which say, “This is definitely a national problem,” and we have on the other hand Baroness Amos’s review, which says, “Well, it isn’t,” how do you back your argument up? What evidence should we be looking for to ensure that we can support what you are saying? Where can you point us?
Donna Ockenden: I would point you to “Intrapartum Care”, which is the labour chapter and gave lots of examples, the “Antenatal Care” chapter, the chapter on women’s voices and the chapter on staff voices. That’s Nottingham. Shrewsbury is now four years old, but there was significant evidence there. Of course, Dr Kirkup is a very well-respected colleague. He has done East Kent, and he has done the Morecambe Bay report, which goes back to 2015.
Q79 Gregory Stafford: I know you can’t predict this, but would you be surprised if similar pressures and issues were in, for example, the Sussex area, which you are about to look at?
Donna Ockenden: We will have to wait and see, but yes, I have spoken to women who have used all four units in Sussex and increasing numbers of staff are coming forward. The jury is out, so to speak. We will approach our work with absolute diligence, and we will ensure that women and family voices and staff voices are heard, reported and acted on.
Q80 Chair: On the Amos review, do you feel that the six-month timeframe, given that it has told us nothing that you had not already said somewhere, is the right timeframe or do you think it should try to do its work faster?
Donna Ockenden: Do you mean the taskforce creating the action plan?
Chair: Yes.
Donna Ockenden: I have to speak as I find, and I have said that we don’t have the luxury of six months. And that is an action plan by the end of the year. How long does it take, once the action plan is out and Christmas and everything is done, to then get that implemented? 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 could be caused, I would say that we don’t have six months to create an action plan. That would be my view.
Q81 Chair: On the question of a statutory public inquiry, which has been picked up by a number of families across the country, what is your view? Valerie Amos’s was in the negative.
Donna Ockenden: I think it will be important for the Committee to listen to family views, and I did ask them if they were able to attend, as you had requested me to. I understand where families are coming from. The vast majority of families that I have known, over decades, say that they want two things: they want not only answers, but assurance that what happened to them will not happen to anyone else. Where they are left sitting at the moment is that not enough has been done to give them that confidence, so I fully appreciate where they are coming from.
Chair: If I had to press you for an answer, do you back it or not? Baroness Amos was a no at this stage. Is the jury still out, on balance?
Donna Ockenden: The jury is still out. I note that the Secretary of State has said he is not taking anything off the table.
Q82 Ben Coleman: This has been interesting. Thank you for your work. It is extraordinary and very important. To come back to the action plan and maternity commissioner, I get the sense that you feel that the action plan could be written in a week.
Donna Ockenden: I think it should be done by now.
Q83 Ben Coleman: A week since your report and Baroness Amos’s, and you think it should be done by now. Given your experience, why do you think that the Government think it needs to take six months?
Donna Ockenden: I do not know, because as I explained to Dr Cooper, throughout the Nottingham report, we were meeting very senior NHS leaders, we were meeting the trust and we were keeping them informed of our findings—we will do that throughout Sussex, too, I promise you. That is probably the reason why I would say, “Why are we saying we need six months to write an action plan?” There was enough knowledge—
Q84 Ben Coleman: And the money behind it, maybe?
Donna Ockenden: We are spending the money already—we have to be really clear that we are spending the money on the cost of harm, not that that can ever compensate families for what they go through. I am sure some very clever economists somewhere could say, “We are spending this on harm. How do we turn that back around into better care?” I am not an economist, but I am sure there must be a clever will and a way somewhere.
Q85 Ben Coleman: As I mentioned—we have talked about this already with Baroness Amos—the Government announced that they are going to create this maternity and neonatal commissioner role. I think you have said that you do not want to take on the role yourself—
Donna Ockenden: I haven’t been asked!
Q86 Ben Coleman: If you were asked, would you take it on?
Donna Ockenden: Well, I think we would have to understand more about what the role was and what resources underpinned it. First of all, a maternity commissioner has been asked for in multiple reports, going right back to Baroness Gohir in 2022 and further, so this is not the first time around the fence.
Q87 Ben Coleman: It has been agreed, though, hasn’t it?
Donna Ockenden: Yes, it is probably the first time it has been agreed. Clearly, we would have to understand what the powers were and what the infrastructure was behind it, because I do not think that one person can fix everything.
Q88 Ben Coleman: Do you see a world in which—with the appropriate infrastructure, resources and powers—it would be helpful, or not?
Donna Ockenden: Potentially, yes.
Q89 Ben Coleman: Would you be more interested yourself in helping to do that if all those things were in place?
Donna Ockenden: Well, I have quite a lot on at the moment.
Q90 Ben Coleman: I think that brings it to a close, but I will restate it: you do see a role, properly resourced, for the maternity commissioner.
Donna Ockenden: Potentially, yes. I think I would want to know more about it.
Q91 Ben Coleman: My last quick question is this. We are going to have six months—we have major comments on the length of time—for the plan to be developed. The commissioner would come in only some months after that, even. Would that make the job more challenging, or is it still doable?
Donna Ockenden: My understanding is that the request is for the commissioner to co-chair the taskforce—I think that is what I heard today, and that would be a good thing—with the Secretary of State. I guess every effort would then need to be made so the commissioner was not responsible for introducing work they might not have had influence on. That is one reason why we need to move at speed and at pace with this action plan.
Q92 Ben Coleman: Because it is statutory, which is a good thing, it can take a bit of time. It is going to be brought in with the Health Bill, and that is not going to come to its end for a few months.
Donna Ockenden: I think time is not on our side.
Ben Coleman: You could have a plan next week, but a commissioner might not be in place for another eight months.
Donna Ockenden: Exactly, and that is a concern.
Q93 Ben Coleman: So we need to bounce ahead, even without a commissioner. Then the commissioner is going to come up and say, “What have you been doing? You’ve got it all wrong”—or not.
Donna Ockenden: I don’t know. We will have to see.
Q94 Chair: We heard from the last panel that it was suggested that the commissioner should have the power to compel the creation of new datasets and so on. What other powers is it critical that the commissioner has—powers that might, for example, be written into legislation? Can you be specific about that, so we can recommend it?
Donna Ockenden: Yes. I was really moved to hear all the discussion in the House about the Hillsborough law. It was really moving. I do think that compelling people to speak is really important. The role has to be resourced. The fact that it is on a statutory footing is really important, but the structure underpinning it has to be given considerable attention.
Q95 Chair: Who it is accountable to, and so on?
Donna Ockenden: Absolutely.
Chair: Thank you very much.