With permission, Madam Deputy Speaker, I will make a statement on the independent review of maternity services at Nottingham University hospitals NHS trust. Donna Ockenden’s review is the largest into a maternity service in the history of the NHS. The nature and sheer scale of the failings it exposes are horrific. It uncovers dangerously and tragically deficient care at almost every turn. Its findings and conclusions are chilling. The report covers 13 years, including accounts from 838 members of staff and, crucially, the experiences of 2,536 affected families. I met a small number of those affected families last week, and I felt numb after hearing the depth of their pain. I felt even more numb when I considered how many families not in the room went through such trauma too, and the forgotten children who survived but live every day with the consequences of maternity care failings. I felt devastated that so many women and babies, as well as their fathers and other family members, had suffered injury, death and lasting trauma while under the care of the NHS. Now having met the families, and having seen the report, I feel appalled by the neglect, incompetence, racism, discrimination, contempt and harassment that so many suffered. I feel heartbroken to know that, so many times, when they tried to raise the alarm about their care, they were ignored, sneered at, disbelieved, blamed and lied to. How on earth could this have happened? There is no single answer, but Donna Ockenden shines a light on what was going on. First and foremost, women were not listened to. Donna Ockenden says that the staff shortages and lack of training in Nottingham were among the worst she has ever come across. Bullying by doctors and senior midwives was rife, which meant that staff who tried to speak up were intimidated and ridiculed. There was a culture of cover-up at the highest levels of the trust, and there were ineffective and inadequate responses from regulators. Perhaps most damning of all, for years the trust ignored evidence of clinical and cultural flaws in both internal and external reviews that it had itself ordered. When I met Donna Ockenden last week, she told me that those inquiries were “diligent” and of “good quality” but that they were effectively swept under the carpet by the board. That refusal to act is unforgivable. Donna Ockenden and her team deserve huge credit for their forensic and compassionate approach, as does my hon. Friend the Member for Sherwood Forest (Michelle Welsh), herself a harmed mother, as well as Members for neighbouring constituencies who have walked side by side with their constituents through years of anguish and struggle. However, the driving force behind the review has been the affected families themselves. They have demonstrated more patience, more courage and more tenacity than one might imagine is possible from those dealing with broken hearts that will never mend. Though each of their experiences is unique, one feature is common: at the very moment when they were at their most vulnerable, they placed themselves and the lives of their unborn babies in the hands of the NHS—and the NHS failed them catastrophically. To all those who have suffered so appallingly, I say today, on behalf of the NHS: I am sorry. I am sorry not just for the failures, or the heartless and undignified treatment, but because your cries of concern went unheard for too long—and so the Government will act. We will act by taking immediate steps, including to expand Martha’s rule to all maternity and neonatal settings so that parents can demand a second opinion if they feel their concerns are being ignored. I know that some people may want me to accept all the review’s recommendations today, but in the past too many recommendations have been accepted and then have sat on a shelf gathering dust, and we have seen more deaths and more suffering. I do not want to let down the families I met in Nottingham, or bereaved parents anywhere else in the country. I want to use the national maternity and neonatal taskforce, which I chair, to create a comprehensive action plan to be published by the end of this year that will address all the national-level recommendations from this review and others. I am confident that work will be welcomed by all those midwives, obstetricians, paediatricians and other healthcare workers who strive every day to make sure that babies are born safely and that women receive outstanding levels of care. It is clear that, in case after case, families felt that regulators, including the General Medical Council, the Nursing and Midwifery Council and the Care Quality Commission, were more concerned with protecting clinicians than with providing accountability. That is damning and that is wrong. As one grieving mother told me: “They put the fox in charge of the hen house.” Clinicians and trust leaders must know that their behaviour will be properly scrutinised and that their actions will have consequences. We must meet the test of the Nottingham victim who told me last week that “accountability drives action”. We are making changes to the CQC, one of which is to extend the cut-off period to initiate proceedings from three to five years so there is more time for families to bring cases. I will also call in the chair and chief executive of the GMC to hear directly their account of the failures at NUH. Let me be clear: if their response falls short, things will change at the GMC. From speaking to families in Nottingham, I know that there is real and understandable anger that some leaders and clinicians at the centre of this review were able to avoid giving evidence. Today, I make a commitment that, when passed, we will use the Hillsborough law’s duty of candour to ensure that witnesses in upcoming reviews of maternity service failures, including those in Leeds and Sussex, can be forced to provide evidence. That change will make sure no one is able to refuse to co-operate in the search for accountability and justice ever again. There is so much in the stories of the families in Nottingham that is shocking and heartbreaking, but the way the bodies of their loved ones were handled by hospital mortuary services revealed a level of disrespect and a lack of humanity that—I will be honest—left me utterly aghast. The details are disturbing, but they need to be heard to understand the gravity of what families were confronted with: deceased babies referred to as a “specimen” or “sample”; a baby placed into a mortuary space already occupied by an unknown and unrelated adult; a baby disposed of as clinical waste against the express wishes of their parents; and a baby kept in a domestic fridge in a bereavement room. The emotional and psychological effect of those dehumanising failures was to layer the most profound disrespect on the most unbearable distress. There is also evidence that the trust actively decided not to report failings in mortuary care to families. As hon. Members will know, there is an active police investigation and arrests have been made, which limits what I can say. As a start, however, I have asked NHS England to write to trusts to make sure these appalling experiences are not happening elsewhere in the NHS. I confirm today that the Human Tissue Authority will require all mortuaries to review internal records going back 10 years to ensure all incidents have been logged and reported. I have instructed them to report the findings directly to me by 16 October. When I met the Nottingham families last week, they also raised with me the issue around what are known as secondary victims. In maternity settings, fathers, partners and others are actively encouraged to be present to support mothers through labour and delivery. However, the law does not allow them to bring their own claims for the psychiatric illness suffered as a direct result of witnessing their partner or baby suffer injury or die. I have therefore asked David Lock KC to work with my officials to consider that important issue as part of his wider work on clinical negligence. Donna Ockenden acknowledges that NUH has not waited for her findings to be published to start making improvements. I will speak to the chief executive next week to interrogate the trust’s response and make sure there is a proper plan in place for implementing the recommendations speedily and effectively. But there is a long road ahead before NUH fully addresses all the issues and before it can possibly regain the full trust and confidence of the communities it serves. I close where I began: with the families. Nothing can make up for what they have gone through, but this report is a tribute to their resilience and tenacity. I say to them directly: you had to drive this for so long, but you are no longer driving this alone. We are with you and we will not stop until you have the accountability and the justice you deserve. I commend this statement to the House.

I call the shadow Secretary of State.

I thank the Secretary of State for advance sight of his statement and Donna Ockenden and her team for the care and compassion with which they conducted the review. We had a meeting with her yesterday, and I have to say that it was probably one of the most difficult meetings that I have ever had. I pay tribute to the hon. Member for Sherwood Forest (Michelle Welsh). I can see how deeply personal and painful this is, and I admire her and all her colleagues from the region at what must be a very difficult moment. Let me say from the outset that I want to be constructive in opposition when it comes to this issue. We need to work together; we have to see improvements. I begin with the women, babies, fathers, partners and families whose lives sit behind the review’s findings. To them, we owe a profound apology for failing them when a family should feel safest, most supported and most able to trust the care around them. For too many, that trust was broken; women were not listened to, families were not believed and warning signs were missed. Some suffered the deepest lost, others were left physically unsafe and others psychologically scarred. No statement can repair that pain, but it can mark the point at which testimony becomes responsibility, and responsibility becomes action. The painful truth is not only that the failings occurred but that the themes are familiar: women not heard, families dismissed, poor communication, missed deterioration, weak governance and people unable to speak up. Maternity and neonatal safety has challenged Governments of both parties, but it would be wrong to let that history soften the urgency. Women and families are tired of telling their story, hearing promises and seeing the same themes return. The question is whether the system will move because of this review, and so I put three tests to the Secretary of State. The first is the listening test. Women and families were not consistently listened to. Their concerns were too often dismissed or not acted upon. That is not a soft issue; it is a safety issue. How will the Government embed listening as a clinical discipline? How will trusts measure whether women feel heard? Will complaints and near misses be treated as information for improvement? The second is the culture test. The review describes bullying, hierarchy and poor psychological safety affecting staff’s decisions and willingness to escalate. I pay tribute to those who were brave enough to do so. In maternity and neonatal care, minutes matter. If staff cannot challenge, safety is weakened. Staff cannot provide the care they want to if they are exhausted or unsupported, or if hierarchy matters more than candour. So I ask: how will boards be held accountable for that ward culture? The third test is the delivery test. Harm rarely followed one error; it usually followed a chain of poor communication, weak risk assessment, delayed escalation, staff pressure, inadequate governance and missed learning. The response cannot be a single announcement. It must be accompanied by a delivery plan, so will the Secretary of State publish a national implementation plan with named accountability, delivery dates and regular updates to this House? That plan must address the workforce so that staff have the support and information they need to fulfil their roles to the ability they wish. That plan must design services for today and the future, not rely on assumptions from the past. Women are having children older, pregnancies are more complex and more women are entering pregnancy with pre-existing conditions, previous loss, fertility treatment, mental health needs or circumstances shaping care. That means a need for practical, personalised care, informed choice and each woman being treated as a whole. The review also requires us to confront inequalities. The safety of a patient must not depend on confidence, class, ethnicity, language or an ability to fight through the system. The issue with our mortuaries is also really shocking. The horror stories that we have heard must never happen again. Is the Secretary of State working with colleagues in the Department of Justice to see what more needs to be done to overhaul this area? Finally, we must recognise the psychological harm caused through silence, poor communication, lack of bereavement support and the battle for honesty. We know that our mortuaries need to have the highest standards. Compassion after harm is not a courtesy; it is a duty. Trust is rebuilt when women feel the difference in the room, when words change decisions, when staff speak without fear, when risk is escalated in time and when boards are judged by results. Where the Government act to improve safety, accountability, staffing and family voice, they will have our support so that we can see this through together. Where they do not, they will face our scrutiny. This review began with families who had to fight to be heard. The task now is to ensure that no family has to fight so hard again.

I thank the shadow Secretary of State for not only the content but the tone of his response, and for the approach that he has taken. I firmly welcome this collaborative approach, because he rightly points out that this is an area that we should work across parties and across this whole House to address. His summary of the key issues that we must address through the work that we are doing—first and foremost, ensuring that women are listened to; the cultural changes we need to see; and the delivery test, recognising that this is a chain of failure—was very well made and in line with where I and the Department are coming at this issue from. As I mentioned earlier, all the recommendations from today’s report, as well as the recommendations from the national report that Baroness Amos has been working on and from other inquiries and reviews of maternity service failures, will come to the national taskforce that I chair, precisely to deliver that delivery plan—that comprehensive plan of action. We will ensure that it is published by the end of this year, and the Government, working with the Opposition, will ensure that it is delivered across this country.

I thank the Secretary of State for his statement. For openness and transparency, I note that I have been campaigning on this for six years and I am a harmed mother at Nottingham University hospitals NHS trust. I start by thanking the brave families—my friends—and Donna Ockenden and her team. What has happened is horrific: bullying, cover-ups, racism, discrimination and appalling practice. The way babies have been treated at birth and then at the end of their life is a national disgrace. One of the most uncomfortable truths in this report is that it was not a regulator, a policy, a protocol, a law or a Government Department that brought us this inquiry; it was families—bereaved families, harmed families—having to speak again and again about their most horrendous and traumatic experience for more than a decade. That does not signify a system that is working. The report identified avoidable deaths, harm and profound failings. The publication of this report is simply not enough. What is required now is action, accountability and change. Can the Secretary of State therefore assure the House that there will be a plan with robust oversight and questioning of regulators and senior staff? Will he work with Nottinghamshire families and Nottinghamshire MPs to ensure that justice is truly and fully delivered?

I thank my hon. Friend for her questions. Let me put on record again how much I have appreciated her advocacy, her support, her sharing of her own experience and her standing up for the many hundreds of families in the area she represents. Her contribution is invaluable to this most important work that we are doing as a Government. She talked about families driving this report and making sure that it happened, and she is absolutely right. I met some of those families last week in Nottingham, and as well as feeling numb at the depth and breadth of their pain, the feeling I left with was a sense of their exhaustion at having fought for so long to be listened to and to get this into the open. Our responsibility as a Government and as MPs is to say that, now it is out in the open for us all to see, we all bear a responsibility to help them carry this forward. I take that responsibility with the utmost seriousness. My hon. Friend asked about a plan to change maternity services in Nottingham and across the country. There will be specific local recommendations in Nottingham, and I am meeting the chief executive of the trust next week to pick that up directly with him, but there are more recommendations in the report that will have national implications, along with the recommendations from the national review that is under way. It is crucial that all those recommendations are formed into a plan of action, and the taskforce that I chair will be crucial in making sure that these recommendations do not just get accepted and then sit on a shelf gathering dust, but form a plan of action that we can stand behind as a Government. Finally, my hon. Friend mentioned the importance of action, accountability and change. I repeat what I said in my statement: one of the phrases that stuck with me powerfully from my meeting with Nottingham families last week was from the person who said that “accountability drives action”. Without that accountability, we cannot have a guarantee of action. That is why the accountability that the families seek is the change that we as a Government must seek to deliver.

I call the Liberal Democrat spokesperson.

May I start by acknowledging the hon. Member for Sherwood Forest (Michelle Welsh), Donna Ockenden and the Secretary of State for the statement and for their hard work? I thank the Secretary of State for the actions that he has proposed so far, which I think are the first tangible actions we have heard in this place. I must also acknowledge the incredible courage and resilience of the Nottingham families who have been instrumental in bringing about this review. No one can imagine the pain that they have gone through. I am distressed and angry to be stood here once again speaking about babies who should not have lost their lives, mothers who should not have lost their lives and trauma that families should not have experienced. Review after review has led to 748 recommendations since 2015, but birth injury and mortality rates have continued to rise. These reviews all reveal similar issues: unsafe staffing levels, lessons not learned, issues not escalated, insufficient training, and women’s concerns ignored. Four years ago, after the Shrewsbury review, we found that over 200 babies had died unnecessarily in Shropshire, yet things have got worse. Donna Ockenden’s Nottingham report reveals new and extremely distressing revelations about serious failures to protect the dignity of the deceased in after-death care, something that must be addressed through proper regulation. Liberal Democrats have put forward a maternity rescue package that would guarantee one-to-one midwifery care and introduce a national maternity commissioner to oversee vital improvements. It would be nonsensical for the Government not to take a strategy forward. Will the Secretary of State pledge to implement every single one of the Nottingham report’s essential actions, and to work with us to deliver the essential investment we need to make Britain a safe place to have a baby, and end this shocking cycle of failure? Anger is not enough. Mothers, doctors and midwives are sick of seeing review after review and being met with stasis, with the same failures repeated over and over again. This must be the moment we say, “Enough.”

I thank the hon. Lady for her words. When she spoke about ending this cycle, she sums up a feeling that I think many of us have: the cycle of inquiries and investigations revealing what has been happening in maternity services and leading to recommendations, which are accepted, but then things do not change enough, and action is not taken to address all the issues raised. That is the cycle we need to break. The national taskforce, which is established and which I chair, will take all the recommendations from Donna Ockenden’s report, as well as those from Baroness Amos’s national review, which will be published shortly, as well as some of the other hundreds of recommendations that the hon. Lady mentioned, and ensure that it produces a comprehensive action plan by the end of the year. The challenge for us is not simply to accept recommendations, but to produce and deliver that action plan.

Today’s publication of Donna Ockenden’s report into maternity services in Nottinghamshire is a difficult and deeply emotional moment for families across our county and city. I want to place on the record my thanks to Donna Ockenden and her outstanding team for the care, compassion and thoroughness with which they have exposed the devastating cases of these families. Let me also place on the record my thanks to my hon. Friend the Member for Sherwood Forest (Michelle Welsh). She is a fearless and formidable campaigner for justice and has walked this journey with the families every step of the way, and I know just how proud her son Billy will be watching her from home today. My thoughts are first and foremost with the families whose lives have been changed forever by the loss of their babies, and the mothers who should have received safe care but were harmed. Behind every page of this report are families who have endured unimaginable grief and who have spent years fighting simply to have their voices heard. I pay tribute to their courage, dignity and determination. In the face of heartbreak, they refused to be silenced. They fought not only for answers about their loved ones, but to ensure that other families would not suffer the same pain. Can my right hon. Friend confirm that he will consider all options available to deliver justice and accountability for those families who have waited far too long for answers? Will he assure me and the whole House that the lessons identified in the report will be fully implemented and embedded throughout maternity services in Nottinghamshire and around the United Kingdom, so that no family has to endure what far too many families have already endured?

I thank my hon. Friend for his comments and questions, and I echo his words about paying tribute to the courage, dignity and determination of the families who have driven the report and driven these shocking failures out into the open, so that we can all see the scale and depth of what has happened. He asks me about embedding the lessons from the review. I assure him that my priority is to ensure that the local lessons around the situation in Nottingham are embedded, and I will meet the chief executive of the trust next week, but also that those recommendations that have implications about national maternity services are taken directly into the taskforce that I chair, along with recommendations from other reports, and that we produce that plan of action by the end of the year. Let me also reassure him that, in that search for change, justice and accountability, I will take nothing off the table.

I call the Chair of the Health and Social Care Committee.

I, too, pay tribute to those families who came forward with their stories, but also to the thousands, if not tens of thousands, of families across the country who are hearing these stories today and are triggered because it reminds them of their own, including in my area in Oxfordshire. What struck me most about the report was the section on leadership and culture, and how when midwives and members of staff raised the alarm, they did not have access to the board, and board members were not curious enough to ask the right questions. I am also struck that in the Secretary of State’s answers—he is right to point to the national recommendations that are yet to come; our understanding is they are coming next week—he failed to mention whether there will be any pot of money to ensure that any recommendations that need double-running in order to happen quickly will have the necessary resources. Can he assure the House not only that will his taskforce seek to implement these recommendations, but that he will ensure that the money exists for staffing, training and buildings so that they are implemented as quickly as possible, so that we do not have to sit here crying on these Benches on behalf of our constituents any more?

I thank the hon. Lady for her comments. She speaks about funding, which is of course a very important part of the response that we need to have to the failings in maternity care. We are investing £25 million, as I am sure she is aware, in tackling the causes of maternal death, to enhance bereavement facilities and to improve triage facilities, as well as £145 million through the estates safety fund to address safety risks in the maternity and neonatal estate. For me, this is not just about funding; this is also about culture, exactly as she says. When there is a culture of mothers and midwives not being listened to, and of the board, in this case, commissioning reviews and then ignoring them, that is where the problem lies. That is what we need to change. There is no single lever we can pull, no single change we need to make; we need to ensure that, from top to bottom, maternity services are overhauled in order to be fit for the future.

First, I want to thank the families who were bereaved and harmed by Nottingham University hospitals NHS trust—some of the most courageous and selfless people I have had the privilege of knowing, including my hon. Friend the Member for Sherwood Forest (Michelle Welsh). They have for years relentlessly pursued the truth, justice, accountability and real change, often at great personal cost, and not only for their own families but to prevent future families having to endure similar trauma and cruelty. I also want to express my sincere gratitude to Donna Ockenden for her service to Nottinghamshire. I am so thankful that it was her who led this review. The scale and magnitude of the systemic failures uncovered by the review are truly harrowing. Mothers and babies were harmed and even died through the most shocking negligence and indifference. Families were lied to, disbelieved, blamed and gaslit. Mistakes were covered up and regulators failed to do their jobs. One of my constituents included in the review summed up well where we go from here when she told the Secretary of State that “we need immediate action and we need long-term accountability”. On immediate actions, will the Secretary of State set out a timeline of when he expects to be able to implement the recommendations in full? On accountability, is he open to a statutory inquiry, provided that it does not delay criminal proceedings?

I thank my hon. Friend for her comments and questions. As well as thanking the families for what they have done to drive the report forward, she also thanked Donna Ockenden for her critical work in producing this report, and to those thanks I add my own. My hon. Friend asks about the timetable for action. The national taskforce, which I chair, will draw together all the national recommendations, all the recommendations from Donna Ockenden’s report, the recommendations from Baroness Amos’s report, and any other report on failures in maternity services, and the taskforce will report by the end of the year. That will be the timetable for us ensuring that there is a comprehensive plan of action. I know from my conversations with families that some have wanted a public inquiry and others have had different views. Let me be clear that, for me, no options are off the table.

It is a matter of profound shame for all of us in the House that in a society that we call compassionate, a baby’s body could be disposed of as clinical waste. I add my thanks to the families and salute their courage, including the hon. Member for Sherwood Forest (Michelle Welsh), and particularly Jack and Sarah Hawkins, and all those families who have shown such courage in coming forward with these utterly appalling stories. I commissioned a number of maternity reviews, and I am afraid that today I feel a terrible sense of déjà-vu. I worry that a lot of the recommendations, and the things that I suspect the Government will end up doing, amount to central direction and central control, which we know usually does not work in the NHS. I was encouraged that the Secretary of State, in his thoughtful comments, used the word “accountability”, because the core problem is a lack of clinical accountability. For his solutions, will he consider a complete overhaul, so that every mother, the moment she knows she is pregnant, is given a small team, including a doctor and midwives, and is told, “This is the team, this is the person who is responsible for the safe birth of your child”, so that she always knows who to go to? That is where things are currently falling between the seams. Ensuring that people always know who is responsible and who to go to is the only way that we will stop these things happening time after time.

I sincerely thank the right hon. Gentleman for his comments. I have a great deal of respect for him, as he knows, so I very much appreciate him making his suggestions in that manner. Let me add to what he said about Jack and Sarah Hawkins, who I met last week in Nottingham. Their sheer determination to push for accountability and justice is incredibly humbling. The right hon. Gentleman mentions the importance of clinical accountability, which gets to the core of how to drive change in the NHS—as he knows, and as I now know, that is not always possible through central control, or by instructions being sent out from the Department of Health and Social Care or NHS England. We must ensure that the entire system is structured in the right way to provide that accountability and to drive change and action, and I will put under careful consideration his suggestion about how that might be achieved.

Today’s publication of Donna Ockenden’s report has laid bare absolutely appalling and systemic failures in maternity services in Nottinghamshire, with thousands of families suffering avoidable harm, and in many cases feeling ignored, dismissed or let down by the very institutions that were put in place to protect them. The report identifies profound failures of leadership, governance and accountability, and an inability to learn from mistakes. Given the scale of the failings and the repeated concerns raised in previous maternity reviews, is it now time for the Government to establish a full, judge-led, statutory public inquiry, with the power to compel witnesses, and examine whether wider NHS and regulatory failures have allowed these tragedies to occur over such a prolonged period?

My hon. Friend raises the important issue of compelling witnesses to give evidence. Although many members of staff contributed towards Donna Ockenden’s review, I found the fact that so many senior leaders did not shocking, and I think it is unacceptable. We will change that by ensuring that the duty of candour, which is due to come in under the Hillsborough law once that is in place, will apply to future maternity reviews, including those taking place in Leeds and Sussex. As I said a few moments ago, there are different views among different families about whether they do or do not want a public inquiry, but I am not taking any options off the table.

May I put on record my admiration for the 2,500 families across our county of Nottinghamshire who gave evidence to Donna Ockenden and shared what were undoubtedly the most personal stories that one could ever imagine sharing as a parent? I will never forget a family coming to see me at my surgery, who said they had been told that their time was up when they were sitting together with their baby, and they were asked to leave. They went to the café, and then they sat on the floor, on the kerb in the car park, and cried together. They said that it was like being shooed out of a restaurant by a rude waiter, not literally the most heartbreaking moment in someone’s life. I was very disturbed to read for the first time revelations about the mortuary service at Nottingham, which is frankly astonishing. It seems as if the right steps are being taken, but we all hope that those responsible for that feel the full force of the law. Nationally, I hope that every hospital trust reading the report now treats the situation as the emergency it truly is. It is astonishing that the NHS is spending almost as much on negligence claims as on maternity services themselves, although of course the money is nothing compared with the misery and pain that has been inflicted on families. For our hospitals in Nottingham, improvements seem to have been driven by ensuring that there is now regular and high-quality training, which was sadly very absent for a long time. Can the Secretary of State assure me that mandatory and regular training is now ensured in all maternity hospitals across the country?

I thank the right hon. Gentleman for his remarks. The story he told was of yet another horrific and harrowing experience that a family has gone through in this scandal. He asked whether we want to prioritise a focus on regular and high-quality training across the country, and I think it is essential to ensure that such training is in place. Although I do not want to prejudge the action plan that the taskforce I am chairing will produce, I cannot imagine a world where training is not a key part of that. Having seen the report, and spoken to families and to Donna Ockenden, my strong feeling is that no single action will transform the system on its own, and that we need a comprehensive plan from every angle to truly transform maternity services across the country.

My mum was a midwife, and as a child I lived vicariously the life on a maternity ward. She worked to the very highest standards possible, and used to come home and talk to me about sloppy standards, falling standards and insensitivity. What happened at NUH is the lowest of the low, and I send my thoughts and condolences, and pay tribute to the families, and to the staff who tried to whistleblow. The memories of the babies must never be forgotten; it is our responsibility to ensure that those memories live forever. I also pay tribute to my hon. Friend the Member for Sherwood Forest (Michelle Welsh). She came here with the dedication, commitment and desire to ensure that this report was done. So often she spoke to me about it, and so often she has had conversations with her Nottinghamshire colleagues about what she is doing. We have tried to support her all the way through, and I am so proud to be with her today. I believe this House should congratulate her on her commitment and dedication, to what happened to her child, and to the lost babies and the support she has given to those families. [Hon. Members: “Hear, hear.”] My ask of the Secretary of State is to follow this through, so that the recommendations are implemented, reported on and monitored. I welcome his announcement that he will use the Hillsborough law to ensure that those who have failed to give evidence or to come forward are forced to do so.

I thank my hon. Friend for her comments and I welcome her support for our decision to ensure the duty of candour introduced by the Hillsborough law will apply to future maternity reviews, such as those due to happen in relation to Leeds and Sussex. In terms of the process of what happens next and the implementation of the changes that we know need to happen, I reassure her that the national taskforce that I chair will produce, by the end of this year, a comprehensive plan of action that will be based on a consideration of all the recommendations that apply nationally in Donna Ockenden’s review, as well as the recommendations from Baroness Amos’s review and any other reviews that have issued recommendations on the subject too.

I was not that familiar with the issue of neonatal and maternity services until my constituent, Mr Thomas Hender, contacted me about the tragic loss of his son, Aubrey. He highlighted the battle that he and his family had gone through, and that so many others had been going through. Sadly, these issues have happened not just at the NHS trust in Nottingham, but at those in Morecambe Bay, East Kent, Shrewsbury and Telford, Leeds and Sussex. Some six further reviews and investigations have been carried out. I value the fact that the Secretary of State said that he had an open mind about a public inquiry; I think we need to move in that direction. It was not until the review of care at the Mid Staffordshire NHS trust became a public inquiry that we were able to address some of the issues. The issues facing neonatal and maternity services are present not only in the areas that I mentioned, but they touch on many other corners of the country, and only a public inquiry can address that.

I thank the right hon. Gentleman for his comments and for telling us some of the story of Thomas and his son, Aubrey. On the need for action, I intend the taskforce that I chair, which will consider all the recommendations from Donna Ockenden’s report and other investigations into failures in maternity services, to produce a comprehensive action plan by the end of this year. That will ensure, as I said earlier, that these recommendations do not sit on shelves gathering dust and that they are put into action. I take on board his points about a public inquiry. I know that his views are shared by some of the families, but I am conscious that other families have different views on this matter. What unites them all is a desire for action, accountability and justice. We need to find the best route to deliver that for them, because that is, above all, the most important thing. However, I reassure him, as I have reassured other hon. Members, that for me no options should be off the table.

I pay tribute and give my admiration to the families who have fought so hard and who have been so strong at this time in their lives, when they have had to repeat what they have been through over and over again. Their fight for justice and accountability is truly fought. I also pay tribute to my hon. Friend the Member for Sherwood Forest (Michelle Welsh), who has not stopped this fight and has continued the story, and I commend her for everything that she has done. The findings of the Donna Ockenden review are harrowing. It is indefensible that babies, mothers, fathers and families in my constituency have suffered injury, death and lasting trauma under the care of the NHS. The Ockenden review has made it clear that mothers’ voices were not listened to and that families were not treated with the dignity, respect and compassion that they not only deserve but is expected from our NHS. The indifference that people have shown to families is indefensible. The public listening to the debate at home will understandably be wondering how we are here again and asking when things will change. I say to the Secretary of State: let us not treat these recommendations as just another set of recommendations to put on the shelf, but let us look at them as a catalyst for change and improvement, making sure that inequalities are addressed. Will the Secretary of State outline what immediate steps the Government will be taking on the most urgent recommendations in the review, and set out how they will be monitored and reviewed?

I thank my hon. Friend for her comments about the role of the families in fighting for justice. She is absolutely right that the recommendations of the Ockenden report, Baroness Amos’s report, which is due shortly, and other reviews and inquiries into maternity services must not simply end up on the shelf gathering dust. That is why the process that I have spoken about today, whereby the national taskforce that I chair will produce a comprehensive action plan by the end of the year, is so important. That will give us the right forum to develop a plan across all aspects and from all angles on this horrific scandal, including the inequalities faced by different families from different backgrounds that my hon. Friend alluded to. I agree with her wholeheartedly that this moment and this process that we are now going into must be a catalyst for change.

I thank the Secretary of State for the way in which he delivered the statement and the apology that he issued, which I think will be received as sincere and heartfelt. Hearing the details in the report, I am not angry but ashamed—ashamed that women and babies have suffered so grievously in this country at their most vulnerable moment. It is a moment of shame for all of us. The report and the Secretary of State speak of failed regulation. I was shocked to learn that a “good” rating can be issued by the Care Quality Commission even when there are still ongoing safety failures at a trust. Does he agree with me that no trust should be labelled “good” if it still has the “requires improvement” rating for safety?

The hon. Gentleman makes an important point about regulators and our regulatory system. The report exposes how completely unacceptable it is that regulators have protected their own and what a serious matter that is. We need to ensure that the regulators are doing their job properly, that they have the right mandate to do so and that they have the right instructions about driving up performance in trusts across the country, because otherwise we run the risk of being in a situation in the future where we are again confronted with what he accurately described as shame.

I put on record my thanks and respect for the resolute campaigning of the Nottingham survivors, especially my constituents, Jack and Sarah Hawkins, who have worked so hard to bring these issues to regional and then national attention. They have made sure that baby Harriet’s death was not in vain. I also pay tribute to my hon. Friend the Member for Nottingham South (Lilian Greenwood) who was their MP for many years. As she is a Minister, she will not be speaking in this statement, but she deserves recognition for the steadfast support she gave to them as a family, as well as other families from Nottingham South. I thank Donna Ockenden who, in addition to supporting thousands of families, invested so much time in Nottingham and Nottinghamshire MPs to ensure that we understood the systemic failings that she was working so hard to identify. This is undoubtedly a shameful day for the NHS. Another fearless campaigner from Rushcliffe is Ashley Harper, who has been in touch with me about the maternity and neonatal taskforce and its perceived failure to recognise and support families who have been harmed. She would like to see a family expert for harmed children and a family expert for harmed mothers on the taskforce. I know that these asks have been raised by my brave and hon. Friend the Member for Sherwood Forest (Michelle Welsh), who has done so much for the Nottingham families, but will the Secretary of State say whether that is something he is actively considering?

Let me repeat what I said earlier about my humble admiration for Jack and Sarah Hawkins and their campaign for justice over baby Harriet. My hon. Friend is absolutely right to refer to the failings as systemic. This is not a handful of cases or problems; this truly is a problem that affects the entire system. The culture and the systems that are in place have let people down, and that is why our response must be so comprehensive. My hon. Friend mentions the input of families into the taskforce and his constituent Ashley Harper, who raised that matter. I am very happy to discuss with him after this statement how we can ensure that the taskforce represents the views of all families.

When whistleblowers tried to alert society to what was happening, was any action taken against them, and if it was, does that indicate that there needs to be strengthened protection for whistleblowers? At the other end of the spectrum, are those clinicians who refused point blank to take part in the review process going to be named?

The right hon. Gentleman raises an important part of the dynamic that has been exposed through Donna Ockenden’s review: people not feeling able to challenge what is happening—feeling that they are being intimidated or forced to stay silent—even when they want to raise issues of great importance. We must ensure that the right structures and culture are in place not only so that women and their families can raise their concerns, but so that staff, midwives and others working in maternity and neonatal services have the confidence to raise their concerns through whatever mechanism is most appropriate in the circumstances. They must have confidence in the mechanism to raise their concerns. The right hon. Gentleman spoke about clinicians who refused to take part in Donna Ockenden’s review in Nottingham. As I said earlier, although more than 800 members of staff contributed towards the review, I was appalled at the number of senior clinicians who did not agree to take part. That is why it is so important that we change the law—applying the duty of candour through the Hillsborough law to ensure that this can never happen again.

I thank the Secretary of State for his statement and the confirmation that he will expand the Hillsborough law to apply to those clinicians who did not speak but should have spoken. I also want to put on record my thanks to my hon. Friend the Member for Sherwood Forest (Michelle Welsh) for her leadership and courage, as well as my heartfelt sadness that so many families endured so much harm. This report has been so thoroughly and expertly delivered by Donna Ockenden, and it has to be the watershed moment. A key feature of this report and every meeting with Donna and the families has been an overwhelming sense of failure at every single level: failure to listen, failure to react and failure to prevent harm. The experiences of the harmed families will stay with me forever. Will the Secretary of State outline how the immediate and essential actions, including the first one—listening to women and families—will be the catalyst for the change that we need? What steps will he take in his first day of taking forward this report to ensure that we do not have Nottingham repeated elsewhere?

My hon. Friend asks about the immediate actions that the Government are taking in response to Donna Ockenden’s review. For me, above all else—above all the shocking, harrowing detail—the review highlights the fact that women simply were not listened to. That comes up time and again. I know that it comes up in other aspects of healthcare as well, but it came up so strongly in this report and underlined so many of the shocking failures that have occurred. As a first step, extending Martha’s rule to all maternity services across the country means that when women or their family members are concerned that they are not getting the treatment or care they need, they can get a second opinion—an urgent, independent review. That is an important first step, but this must be a watershed moment that does not rely simply on one action or a small handful of actions. There must be a comprehensive plan to tackle this issue from every angle and to ensure that we have the systemic change that so many Members today have said is crucial.

In the 25 months since Theo Clarke and I produced the first ever parliamentary report on birth trauma, and nearly four years since we discussed the East Kent Kirkup report in this place, we have seen more and more reports, more and more scandals, more and more heartbreaking stories, and several Health Secretaries. Campaigners are grateful to the brilliant Donna Ockenden but, frankly, expectations are pretty low about ending this crisis in maternity care all these years later. Does the Secretary of State agree that as well as training, we have to end this patchwork postcode lottery of care, and introduce basic, nationwide standards and accountability across all NHS trusts?

The hon. Lady makes an important point about the fatigue, weariness and exhaustion of families at so many recommendations being made and accepted but not put into action. To pick up on the point made earlier by the Liberal Democrat spokesperson, the hon. Member for North Shropshire (Helen Morgan), we must now break that cycle to ensure that the recommendations do not simply get accepted and sit on a shelf gathering dust, but that they feed into the plan of action, which will then produce the change that we need to see. As the hon. Member for Canterbury (Rosie Duffield) said, the change must be nationwide. Although we are today rightly talking about what happened in Nottingham, we know that it is far from the only place where such failures in maternity and neonatal services have been seen. We know this is a national problem that needs a national solution.

May I start by saying that my thoughts are with the families and with the babies who have died? I would also like to say to my hon. Friend the Member for Sherwood Forest (Michelle Welsh): I am sorry you had to go through this. It should not have happened, and I am angry. I am a member of the Health and Social Care Committee, and the reason I am angry is that last year we did a follow-up review on black maternal health, and the same things kept coming up over and over again: racism, equality issues, women being silenced, a lack of governance, women not being heard, unavoidable deaths, and a lack of accountability. Where does it stop? There is a lack of training, and the system is failing our women; we have had over 70 recommendations, but that is what we found last year. Every time we say, “Enough is enough”, what happens? We have yet another review. My daughter had a baby a few years ago. If I had not been with her, she would have lost that baby, because it was as if she was invisible. It was not until somebody else went into the room with her and said, “Enough”, that the people there were really willing to listen. These failures are systemic. What worries me is that funding is not ringfenced for maternity services—it can go anywhere in the system. Once this review—or whatever it might be—has been done, what will be done to ensure that the funding follows the recommendations? It is no good having the funding there if it is being run by local organisations that are using it to plug holes. That has got to stop.

I thank my hon. Friend for her comments, and for talking about the shocking situation with her daughter’s baby that she managed to avert. She spoke about the inequalities, the racism and the fact of women being silenced, all of which come through very strongly in Donna Ockenden’s report. As I have explained, the taskforce I chair will now consider the full set of recommendations from that report, as well as the recommendations from Baroness Amos’s national review and other reviews and inquiries into what has happened in maternity services. That taskforce will produce a comprehensive plan of action that will cover the whole range of actions that need to be taken, because we know it will take more than one action, or even a small handful of actions, to transform maternity services and make them as they should be. This is a problem that goes very deep; it is systemic, cultural and deeply embedded, and a comprehensive plan will be required to change that.

The Secretary of State and the shadow Secretary of State, my right hon. Friend the Member for Daventry (Stuart Andrew), are both to be congratulated on the tone and tenor with which they have approached this most sensitive of issues—it is in the very best tradition of this place. It also indicates, I hope, a preparedness to work across the two parties to bring forward speedy solutions to the horrors we are hearing about and have read about in the report. May I ask the Secretary of State two direct questions? First, the management of bodies post mortem seems to fall between his Department and the Ministry of Justice. We have talked far too often about how to regulate that space.

indicated assent.

The hon. Member for Leeds South West and Morley (Mark Sewards) is in agreement. Can the Secretary of State’s Department now grip that issue and drive it forward in order to give certainty to all our people that there is dignity and decency for all in death? Secondly, this issue clearly affects Nottinghamshire most acutely, but there are expectant parents across England today who will be worried about the level of service they can expect and about the outcomes for themselves and their child. What is the Secretary of State proposing to do to communicate with those people, to say that the Government are aware of this issue and are gripping it—that a shake-up is taking place and better services will be provided—as well as to give them some indication of what they can expect, and to give them comfort and confidence in what should be the most exciting period of their lives?

I thank the hon. Gentleman for his remarks, and for his tone and approach in encouraging cross-party working—he is absolutely right that that will be essential for making progress on this most important issue. I will consider the important point he has made about the Ministry of Justice and its remit in relation to what we have seen in mortuary services. As I said earlier, in a report full of shocking revelations, that inhumanity and lack of dignity left me truly aghast; it is almost unbelievable that it could have happened. The hon. Gentleman also raises an important point about women and their families across the country using maternity services. While the conversation we are having today is of course about the failures in Nottingham, we know that most women will receive high-quality care, and the majority of the NHS workforce do an important job supporting them. We should make sure that is acknowledged in this difficult conversation. However, one of the changes we want to make immediately is extending Martha’s rule to maternity services right across the country, because we know it is something we can do now. Martha’s rule is a mechanism that has worked well in other parts of the NHS, and it will mean that when women and their families feel they are not being listened to, they will have a way to get an urgent, independent review of the care they are receiving.

I thank the Secretary of State for his statement, and extend my thoughts to everyone who has been a part of the Ockenden review. I also hugely thank my hon. Friend the Member for Sherwood Forest (Michelle Welsh) for her unending efforts in campaigning for the families we represent in our constituencies, who have been through so much. Of course, I also thank Donna Ockenden for her work, her amazing support, and her constant engagement with us as the local affected Members of Parliament and with our constituents. In the past two years, I have met so many families who have been harmed in ways I cannot understand or comprehend, and have heard of and seen horrors that I can barely believe. In addition to those babies and mothers who lost their lives, it is important that we highlight children like our mate Ryan, who recently turned 18 but who will never be independent because of his acquired brain injury. Can the Secretary of State please reassure the House that he will do everything in his power to support children with acquired brain injuries, such as by recognising their conditions in education, health and care plans?

I thank my hon. Friend for his question. I was personally inspired by meeting Ryan’s mum Sarah when I visited Nottingham last week—she told me about Ryan, and showed such incredible strength and courage in advocating for the forgotten children in Nottingham. I can reassure my hon. Friend and the whole House that I will do everything in my power to support children with acquired brain injuries. We are working on an acquired brain injury plan at the moment, and I am also working with the Department for Education and NHS England on ambitious reforms to the special educational needs and disabilities system, including on the future direction of EHCPs.

Could I draw the Secretary of State’s attention to the Sir Jonathan Michael inquiry and report, which followed on from the David Fuller case at Pembury hospital in my constituency? It dealt with sexual impropriety with cadavers, so there is crossover here. Phase 2 of that report came out in July 2025, and it spoke to the lack of regulation of after-death care of bodies in mortuaries, hospitals that look after cadavers and other organisations. I do not know whether the Secretary of State is aware of that report, but are the Government planning on implementing its ready set of recommendations? Sir Jonathan Michael’s report seems to speak to a lot of the issues that happened in this case as well.

I thank the hon. Gentleman for drawing my attention to that report. We will certainly ensure that any reports containing relevant recommendations are considered as part of the taskforce’s work, because one of the changes that I want to make sure we achieve is to not have so many different reports with hundreds of recommendations that then do not become a plan of action. That is a cycle we are seeking to break through the taskforce’s work by producing a plan of action by the end of the year.

In her remarks this morning, Donna Ockenden noted that maternal deaths are at a 20-year high, and total clinical negligence costs are greater than the money spent on maternity services. That should give us pause for thought. It is a national emergency, one that is causing unimaginable pain. The failure of the regulation is stark, so will my right hon. Friend confirm that we will tackle the culture of defensiveness across medical regulators that has caused such harm?

My hon. Friend is absolutely right to point to regulatory failure, which has been drawn out very strongly by Donna Ockenden’s report. For me, what is completely unacceptable is that in their response to what has happened in Nottingham, they have sought to protect their own. That is something we must change, because it is only through effective regulation that we can have true accountability, and it is only through true accountability that we can get action and change.

I thank Donna Ockenden, the hon. Member for Sherwood Forest (Michelle Welsh), and the Nottingham families for all the work they have done to bring us today’s report about what went on across Nottinghamshire. It is truly shocking. At the same time, they were also supporting Sussex families to get their own justice when those families were repeatedly begging the right hon. Member for Ilford North (Wes Streeting) to appoint Donna Ockenden to review what happened in Sussex. I thank them for their support for other families right across the country. When the Secretary of State was appointed to his role, I shared with him a letter I had written along with Sussex and Leeds MPs, asking for the duty of candour to be written into the terms of reference of the Leeds and Sussex reports. I am so grateful that he has announced today that the Hillsborough law will apply once it is enacted. That is very welcome, but that law has not yet been enacted, and it was delayed in the last Session. Does the Secretary of State know when the Hillsborough law will be enacted, and if he is not clear on that, will he commit to pushing at Cabinet to make sure it becomes law as soon as possible?

I thank the hon. Lady for welcoming our decision about applying the duty of candour to future maternity reviews and inquiries, including those in Sussex and Leeds. We have always been clear that the Public Office (Accountability) Bill—the Hillsborough law—is an important priority for this Government. As soon as it is in law, we will ensure that the duty of candour is applied. Our commitment today is to ensure that NHS staff, current or past, cannot refuse to take part in what the lead investigator wants in future inquiries.

The Ockenden report is shocking and its findings are repellent. As my hon. Friend the Member for Birmingham Erdington (Paulette Hamilton) said, it is shocking how many of its findings also featured in a report on black maternal health that the Health and Social Care Committee, on which I sit, published last September. As she set out, women were not listened to. There was no accountability, weak leadership, a toxic culture, racial inequality, understaffing and poor data gathering. All those things are referenced in both reports, and my hon. Friend the Member for Calder Valley (Josh Fenton-Glynn) pointed out that things have been getting worse over the past 20 years. It used to be the case that women who were black were 4.7 times as likely to die in childbirth or around childbirth as white women. The figure is now only 2.3 times. While we can welcome that, the sad fact is that it is not because things have got better for black women; it is because things have got worse for everybody else across the country. The Ockenden report and its findings on what happened are the culmination of problems that have been building for years. I want to recognise my constituent, Louise Thompson. She suffered terribly giving birth, when the NHS would not listen to her about the care she needed. She is now running a powerful campaign for a maternity commissioner and improved maternal care. I hope she will meet my hon. Friend the Member for Sherwood Forest (Michelle Welsh) soon. The Secretary of State promises a comprehensive action plan to be formed by a national maternity and neonatal taskforce. That is welcome, but we have had action plans in the past and they have not delivered the change promised. Given that record, will the Government commit to publishing measurable targets and firm deadlines within the action plan and to report progress to Parliament at fixed intervals? We need to know, and women across the country need to know, what will really be different this time.

I commend my hon. Friend on mentioning his constituent, Louise Thompson, who is campaigning on this important issue. He mentioned the impact of racism, discrimination and inequality in maternity services and their failures—all raised powerfully by Donna Ockenden’s report today. As I said earlier, the action plan, which the taskforce will be producing, will be published by the end of this year. We are determined to break that cycle where recommendations get accepted and then get left on the shelf to gather dust. We want an action plan that can be implemented. We want to make sure that delivery is set out and is progressed by the Secretary of State and the Department. That is a key part of the accountability in making sure that the delivery plan is put into action.

I thank Donna Ockenden and her team, the hon. Member for Sherwood Forest (Michelle Welsh) and all the Nottingham families who are involved in the development of this report. Today, I am angry and upset for all the families concerned, because this report reinforces what we already know: the maternity crisis must end and it must end now. Babies should have lived and mothers deserved better. The same systemic issues have come up again and again: unsafe staffing, lack of training, unchanging culture and a failure to listen to women. At the same time, we have increasing maternity negligence payouts of £2.5 billion. Following the report today, and bearing in mind the £2.5 billion of negligence payments, will the Minister commit to restoring the service development funding to support complex births and bereavement, after it was cut from £95 million to £2 million?

I thank the hon. Lady for expressing how she feels angry and upset. I think that that feeling is shared by all of us in the House today. The publication of Donna Ockenden’s report today has exposed the lifelong suffering of those families. The details of the action plan will be published by the end of the year, because we want to make sure that recommendations are not simply accepted and then not implemented. The recommendations must go into the taskforce, and the taskforce must produce that clear action plan, which we can then implement, and people can see us doing so. That is the way to break the cycle of recommendations that do not get implemented and to make progress towards the justice, accountability and change that I understand from families is so important to them.

The whole House is appalled by the neglect, contempt, and sheer trauma that these families have faced. I commend their strength and the strength of my hon. Friend the Member for Sherwood Forest (Michelle Welsh), but these themes are chillingly all too familiar. The Secretary of State will be aware that NHS England has taken enforcement action against the Northern Care Alliance in recent weeks over multiple safety concerns. Indeed, staff and I raised serious safety concerns relating to the gynaecology department directly with the trust as far back as last year, demanding urgent action, but little happened. Will the Secretary of State meet me to discuss these issues, and will he outline what action he will now take to ensure that patient safety, adequate resourcing and safe staffing levels are urgently addressed at the trust?

I thank my hon. Friend for raising the important issues that she referred to in her remarks. I am happy to make sure that either me or a member of my ministerial team will meet her to discuss them in further detail.

I welcome the Secretary of State’s statement today. It is a difficult and painful, but that is as nothing compared with what those families have been through. On the shocking details he shared with us about babies’ bodies being mistreated in mortuaries, I am sorry to say that that story will be directly relevant to two constituents I am representing. I would appreciate a meeting with him, however brief, to discuss their cases ahead of his Department’s publication of its decisions on the final recommendations from the phase 2 report of the Fuller inquiry. He will also know that Leeds families at the start of their maternity journey—Donna Ockenden is conducting an inquiry into Leeds maternity services—will welcome, as do I, his commitment to ensuring that the duty of candour will apply in that inquiry. Can he confirm for them and for me that all the lessons that Donna Ockenden and he have learned from this inquiry will be applied to the Leeds inquiry, so that those families get the answers they deserve?

My hon. Friend speaks about his constituents whose experience might be relevant to some of the findings around mortuary services and their failings. I would be happy to ensure a meeting with either me or a member of my ministerial team. As I said earlier, the details of what happened in mortuaries leave me struggling for words, because of how dehumanising, disrespectful and abhorrent that was. I would be happy to make sure that his constituents’ points are picked up as part of that. On learning the lessons from the review in Nottingham and applying that to Leeds and Sussex, we are fortunate that Donna Ockenden will be leading those reviews, having just completed the review in Nottingham. She will be in a strong position to ensure that she goes into that with the learnings she has made from the current review. One of those learnings that I am conscious of is how unacceptable it is that senior leaders refused to take part, for which I can see no justification whatever. I am pleased that, through the duty of candour that have we spoken about today, that will no longer be possible.

Nottingham University hospitals NHS trust is one of the trusts that serves my constituents. For those who have been patients there, or who have had babies who have come to harm—I have met some of them—Donna Ockenden’s report is difficult reading indeed. In respect of the staff at that trust, many of them, often junior and low-paid, are on the frontline providing kind, compassionate, person-centred care, and they will be feeling raw today. We value what they do. We have heard a great deal about the appalling practices in the mortuary. They are subject to a criminal investigation, but I want to reflect on the experience of one of the several constituents I have met who have been affected by what we are discussing today. She came to see me as part of Donna Ockenden’s inquiry, and sadly she had engaged with the trust on a number of occasions because she felt that she was experiencing complications with her pregnancy. She was told to lie down and have a fizzy drink and then have an early night, and, despite repeated calls, she was repeatedly fobbed off. Sadly, her baby died. Behind that is a culture of a failure to engage. There was a very poor culture at the trust—so poor that “FOH” was written in patients’ medical notes and on whiteboards, standing for “F*** Off Home”. How could leaders not be more curious about the practices that were taking place on their watch, and where were the regulators? It is absolutely staggering. We are making some very positive changes in the NHS, but I want to push the Secretary of State briefly on changes we are making to the mechanisms that allow people to feed back on their care. We are winding down the National Guardian’s Office and Healthwatch; we are also removing NHS England, which has a regulatory function—and we know that regulators have failed in the case of this trust. What steps can my right hon. Friend take to ensure that those feedback mechanisms will enable people to be heard and action to be taken, so that we can prevent this kind of scandal from happening again?

I thank my hon. Friend for his comments, and for telling us what happened to his constituent. He asked about some of the wider changes that we are making in the NHS modernisation Bill. The aim is to bring the patient experience across the NHS into the heart of the new organisation that will arise from the merging of NHS England into the Department of Health and Social Care to ensure that the patient experience drives the decisions being taken about how NHS care is delivered, and is at the heart of what we do as a Department and a national health service. However, as the report makes clear, the level of failure in maternity and neonatal services is truly devastating. It demands a specific response, which is why the work of the taskforce will begin and it will report by the end of the year. As my hon. Friend has said, this is not just a case of individual cases going wrong or individual members of staff making the wrong decision. It is endemic, and shows the incuriosity of leaders in maternity services about what is going on and what is going wrong in their services. It is a failure of regulators, it is systemic, and the response to it must step up accordingly.

I pay tribute to those families, whistleblowers and campaigners who simply kept going, and to Donna Ockenden for her report and her approach. The report is damning, and my heart goes out to all the families who are having to relive their awful experiences as they see, in black and white, that their suffering and that of their loved ones was not only horrific and harrowing, but entirely avoidable, if only the leaders had been responsible and accountable, and had just listened. As we heard from my brave hon. Friend the Member for Sherwood Forest (Michelle Welsh), this is a national disgrace that must not be repeated. I welcome Martha’s rule, which gives patients the right to an independent second opinion. I also welcome the Secretary of State’s commitment to using the Hillsborough law to ensure that those who avoid scrutiny are compelled to give evidence and are held accountable in the future, but may I ask him two questions? First, can he confirm that he is working across Government to ensure swift implementation of this law, with clear and transparent timelines, so that these families, who have already waited far too long, can finally see justice? Secondly, what will happen to those who shockingly avoided giving evidence and avoided accountability in respect of this review?

My hon. Friend is right to emphasise quite how shocking it is that people in senior leadership positions refused to take part in Donna Ockenden’s review. I cannot understand how they could make that decision and think it acceptable. That is exactly why the law needs to change. It shows why the Hillsborough law is so important and why it was important to put it on the statute book, and also why it was important for us to decide now to apply that duty of candour to future reviews of the failures of maternity services so that never again can NHS staff, current or past, decide not to take part in the search for justice and accountability that it is so crucial for us to deliver.

I pay tribute to my hon. Friend the Member for Sherwood Forest (Michelle Welsh) for all her work. My heart goes out to those families in Nottinghamshire, and I pay tribute to their work as well. I cannot imagine what it is like to lose a child in those circumstances, but I do know what it is like to see your own child suffer a brain injury at birth. I work very closely with other families with children who have cerebral palsy or hemiplegia, because of what they have been through and what my own family have been through. The reasons why such things happen are often connected with negligence, but they are often a result of other circumstances. In our circumstance, our children were born at 31 weeks, as twins. In other families, it is the fact that this woman is black or that woman is disabled that has caused those issues and that negligence. Will my right hon. Friend act on the recommendations of the Ockenden review and the review that is being undertaken by Baroness Amos, and work to ensure that those disparities are overcome when mothers have a greater risk of these things happening to them?

I thank my hon. Friend for sharing with us his experience of brain injury in his own family, and for reminding us how some of the issues that we are discussing today touch the lives of many people in the House and across the country. We all have a responsibility to act on the basis of the recommendations of today’s report, and I assure my hon. Friend that those recommendations, along with those in Baroness Amos’s report, will enable the taskforce to produce a comprehensive action plan. A key element of that work—this concerns his direct point—will be ensuring that when people are at greater risk of harm, greater risk of being ignored, greater risk of being discriminated against, lied to or not being given the care that they need, that inequality will be addressed.

I was born in Nottingham City hospital, and while the Ockenden report was necessarily bounded by the last 13 years, I think it is important to record that women and children were avoidably harmed and avoidably died in those settings many years before, and the pain is not diminished by the passing of time. As I have listened to these exchanges, I have had at the forefront of my mind those friends and people I grew up with who, many years later, found themselves close to death in circumstances that could have been avoided. As my right hon. Friend said in his compassionate and thoughtful statement, the description of what happened in Nottingham will be all too familiar to families well beyond that city. He will know that Sandwell and West Birmingham hospitals NHS trust is one of the trusts that are subject to particular attention as part of the national investigation. What assurance can he give people in cities such as Birmingham that this time, after these reports and their recommendations, things will change and NHS senior management will be held to account?

Although the report that we are discussing today deals with what has happened in Nottingham over the past 13 years, my hon. Friend is right to point out that it has not just happened in Nottingham and it has not just happened over the past 13 years. When I have spoken to people about this report, even today, so many have shared their own stories from many years ago in all different parts of the country. That reminds us that although the focus of the report is what has happened to the families in Nottingham, this issue affects families throughout the country, which is why, as my hon. Friend says, it is “all too familiar” to so many people when they hear what has happened. That is why it is so important that we develop our plan, which will have a nationwide impact, in order to finally tackle this challenge head-on and ensure that we deliver the maternity and neonatal services that women across the country need and deserve.