Victoria Prentis MP was in the Commons Chamber on Wednesday 29 November to hear the Secretary of State for Health, Jeremy Hunt, announce a new safety strategy for NHS maternity services. New measures include the more effective sharing of best practice, independent investigations into the loss of a baby, and more accessible training for staff.

As Vice-Chair of the APPG on Baby Loss, Victoria takes a keen interest in maternity services. She welcomed the Secretary of State’s announcement and took the opportunity to ask about special training for coroners dealing with baby loss cases.


The following account is taken from the Official Report (Hansard) from Wednesday 29 November 2017.

Secretary of State for Health (Jeremy Hunt): With permission, I will make a statement about the Government’s new strategy to improve safety in NHS maternity services.

Giving birth is the most common reason for admission to hospital in England. Thanks to the dedication and skill of NHS maternity teams, the vast majority of the roughly 700,000 babies born each year are delivered safely, with high levels of satisfaction from parents. However, there is still too much avoidable harm and death. Every child lost is a heart-rending tragedy for families that will stay with them for the rest of their lives. It is also deeply traumatic for the NHS staff involved. Stillbirth rates are falling but still lag behind those in many developed countries in Europe. When it comes to injury, brain damage sustained at birth can often last a lifetime, with about two multi-million pound claims settled against the NHS every single week. The Royal College of Obstetricians and Gynaecologists said this year that 76% of the 1,000 cases of birth-related deaths or serious brain injuries that occurred in 2015 might have had a different outcome with different care. So, in 2015, I announced a plan to halve the rate of maternal deaths, neonatal deaths, brain injuries and stillbirths, and last October I set out a detailed strategy to support that ambition.

Since then, local maternity systems have formed across England to work with the users of NHS maternity services to make them safer and more personal; more than 80% of trusts now have a named board-level maternity champion; 136 NHS trusts have received a share of an £8.1 million training fund; we are six months into a year-long training programme and, as of June, more than 12,000 additional staff have been trained; the maternal and neonatal health safety collaborative was launched on 28 February; 44 wave 1 trusts have attended intensive training on quality improvement science and are working on implementing local quality improvement projects with regular visits from a dedicated quality improvement manager; and 25 trusts were successful in their bids for a share of the £250,000 maternity safety innovation fund and have been progressing with their projects to drive improvements in safety.

However, the Government’s ambition is for the health service to give the safest, highest-quality care available anywhere in the world, so there is much more work that needs to be done. Today, I am therefore announcing a series of additional measures. First, we are still not good enough at sharing best practice. When someone flies to New York, their friends do not tell them to make sure that they get a good pilot. But if someone gets cancer, that is exactly what friends say about their doctor. We need to standardise best practice so that every NHS patient can be confident that they are getting the highest standards of care.

When it comes to maternity safety, we are going to try a completely different approach. From next year, every case of a stillbirth, neonatal death, suspected brain injury or maternal death that is notified to the Royal College of Obstetricians and Gynaecologists’ “Each Baby Counts” programme—that is about 1,000 incidents annually—will be investigated not by the trust ​at which the incident happened, but independently, with a thorough, learning-focused investigation conducted by the healthcare safety investigation branch. That new body started up this year, drawing on the approach taken to investigations in the airline industry, and it has successfully reduced fatalities with thorough, independent investigations, the lessons of which are rapidly disseminated around the whole system.

The new independent maternity safety investigations will involve families from the outset, and they will have an explicit remit not just to get to the bottom of what happened in an individual instance, but to spread knowledge around the system so that mistakes are not repeated. The first investigations will happen in April next year and they will be rolled out nationally throughout the year, meaning that we will have complied with recommendation 23 of the Kirkup report into Morecambe Bay.

Secondly, following concerns that some neonatal deaths are being wrongly classified as stillbirths, which means that a coroner’s inquest cannot take place, I will work with the Ministry of Justice to look closely into enabling, for the first time, full-term stillbirths to be covered by coronial law, giving due consideration to the impact on the devolved Administration in Wales. I would like to thank my hon. Friend the Member for East Worthing and Shoreham (Tim Loughton) for his campaigning on this issue.

Next, we will to do more to improve the training of maternity staff in best practice. Today, we are launching the Atain e-learning programme for healthcare professionals involved in the care of newborns to improve care for babies, mothers and families. The Atain programme works to reduce avoidable causes of harm that can lead to infants born at term being admitted to a neonatal unit. We will also increase training for consultants on the care of pregnant women with significant health conditions such as cardiovascular disease.

We know that smoking during pregnancy is closely correlated with neonatal harm. Our tobacco control plan commits the Government to reducing the prevalence of smoking in pregnancy from 10.7% to 6% or less by 2022. Today, we will provide new funding to train health practitioners, such as maternity support workers, to deliver evidence-based smoking cessation according to appropriate national standards.

The 1,000 new investigations into “Each Baby Counts” cases will help us to transform what can be a blame culture into the learning culture that is required, but one of the current barriers to learning is litigation. Earlier this year, I consulted on the rapid resolution and redress scheme, which offers families with brain-damaged children better access to support and compensation as an alternative to the court system. My intention is that in incidents of possibly avoidable serious brain injury at birth, successfully establishing the new independent HSIB investigations will be an important step on the road to introducing a full rapid resolution and redress scheme in order to reduce delays in delivering support and compensation for families. Today, I am publishing a summary of responses to the consultation, which reflect strong support for the key aims of the scheme: to improve safety, to improve patients’ experience, and to improve cost-effectiveness. I will look to launch the scheme, ideally, from 2019.​

Finally, a word about the costs involved. NHS Resolution spent almost £500 million settling obstetric claims in 2016-17. For every £1 the NHS spends on delivering a baby, another 60p is spent by another part of the NHS on settling claims related to previous births. Trusts that improve their maternity safety are also saving the NHS money, allowing more funding to be made available for frontline care. In order to create a strong financial incentive to improve maternity safety, we will increase by 10% the maternity premium paid by every trust under the clinical negligence scheme for trusts, but we will refund the increase, possibly with an even greater discount, if a trust can demonstrate compliance with 10 criteria identified as best practice on maternity safety.

Taken together, these measures give me confidence that we can bring forward the date by which we achieve a halving of neonatal deaths, maternal deaths, injuries and stillbirths from 2030—the original planned date—to 2025. I am today setting that as the new target date for the “halve it” ambition. Our commitment to reduce the rate by 20% by 2020 remains and, following powerful representations made by voluntary sector organisations, I will also include in that ambition a reduction in the national rate of pre-term births from 8% to 6%. In particular, we need to build on the good evidence that women who have “continuity of carer” throughout their pregnancy are less likely to experience a pre-term delivery, with safer outcomes for themselves and their babies.

I would not be standing here today making this statement were it not for the campaigning of numerous parents who have been through the agony of losing a treasured child. Instead of moving on and trying to draw a line under their tragedy, they have chosen to relive it over and over again. I have often mentioned members of the public such as James Titcombe and Carl Hendrickson, to whom I again pay tribute. But I also want to mention members of this House who have bravely spoken out about their own experiences, including my hon. Friends the Members for Colchester (Will Quince), for Eddisbury (Antoinette Sandbach) and for Banbury (Victoria Prentis), as well as the hon. Members for Lewisham, Deptford (Vicky Foxcroft), for Washington and Sunderland West (Mrs Hodgson) and for North Ayrshire and Arran (Patricia Gibson). Their passionate hope—and ours, as we stand shoulder to shoulder with them—is that drawing attention to what may have gone wrong in their own case will help to ensure that mistakes are not repeated and others are spared the terrible heartache that they and their families endured. We owe it to each and every one of them to make this new strategy work. I commend this statement to the House.

Victoria Prentis (Banbury) (Con): As a bereaved parent, but also as a lawyer who has conducted many inquests, I ask the Secretary of State to consider two points. The first is the fact that not many families will need an inquest to determine what went wrong during the birth of their child. Secondly, will he commit to the training of special coroners, just as we have in military inquests, to ensure that those who deal with these very sad cases are the best equipped people to do so? Finally, on behalf of the all-party group on baby loss, may I thank him for today’s announcement and encourage him in his work to make maternity care kinder, safer and closer to home—and may I encourage him to save Horton General Hospital?

Mr Hunt: First, may I apologise to my hon. Friend, because I should have mentioned her in my statement as someone who has spoken very passionately and movingly on this topic in the House? I will take away her point about specialist coroners, because we are now going to have specialist investigators, which we have never had before. I would make one other point. I hope she does not think I am doing down her former profession, but really when people go to the law, we have failed. If we get this right—if we can be more open, honest and transparent with families earlier on—it will, I hope, mean many fewer legal cases, although I am sure that the lawyers will always find work elsewhere.