National Maternity and Neonatal Investigation
29 Jun 2026 · Commons Chamber · 64 speeches · Official record
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I thank the hon. Lady for her comments, and I am incredibly sorry to hear about her constituents Charlotte and James and their baby Norah. I met some of the families in Nottingham two weeks ago, and the depth of pain was numbing-that is a word that someone in the room said to me-because what was said was so heavy to hear and to understand. What made me feel even more numb was recognition that this deep pain is replicated so many times; there is also the breadth of the pain-the sheer scale of it.... Full speech
I thank the hon. Lady for sharing her experience and raising the importance of this issue for the benefit of maternity services more widely. I am very happy for myself or one of the ministerial team to meet her to discuss this in detail, because it is very important that that is part of the national action plan and our wider response. Full speech
My hon. Friend asks a question about staffing, and ensuring not only that we have the right levels of staffing, but that people in the service have the right responsibilities, so that we do not have members of staff suffering from burnout or having a workload that they cannot cope with. Those are critical issues that the taskforce will consider in its development of the national action plan. Full speech
This week last year, I had multiple pulmonary emboli only a few weeks after giving birth. I am very grateful to Dr Laura Stephens, who saved my life and then was punished for ordering the test which found the emboli. Blood clots are the No. 1 cause of death in pregnant and post-partum women, and yet there is not a word about their risk in any pregnancy pack given out in this country. The national action plan will fail if it does not tackle blood clots as the No. 1 cause of maternal deaths. Will ... Full speech
May I add my thanks to Baroness Amos? I join the Secretary of State in emphasising the importance of culture change, but culture change will not happen without accountability. In all the conversations I had with families who were suffering bereavement, harm to themselves or harm to their children, what shocked me most was the cover-up culture in the NHS, which persists to this day, and was exposed once again by Donna Ockenden in her report last week. There is a legitimate debate to be had about ... Full speech
My hon. Friend is absolutely right. I again put on record my thanks to her for supporting families in their fight for justice and accountability. She is absolutely right to say that families have driven this work. It is families who have had the determination, persistence and stamina. It is quite hard to imagine people having those qualities when they are dealing with such unimaginable pain that lasts their whole life, but that is what families have done. That is why I feel that it is our respon... Full speech
I thank the Secretary of State for advance sight of his statement, and I thank Baroness Amos and her team for their compassionate work. As I said last week, I pay tribute to the women and families who gave evidence and to the babies at the heart of the inquiry. Many revisited the most painful moments of their lives after years of fighting to be heard. Their courage places a responsibility on us all. Last week, the House confronted Donna Ockenden’s devastating findings in Nottingham. Today we fac... Full speech
Last Wednesday, and again today, the Secretary of State expressed his shock at the number of senior clinicians who refused to take part in the Nottingham review. May I repeat a suggestion that I made last Wednesday? Those clinicians should be named publicly. That is a step that he could take straight away. If a parliamentary question for written answer is tabled, asking him to name those clinicians, will he answer it? I cannot think of a better or more justifiable use of parliamentary privilege. Full speech
I thank the right hon. Gentleman for his comments. Again, I agree with him and my right hon. Friend the Member for Ilford North (Wes Streeting) on the importance of accountability for changing culture. During the statement on Donna Ockenden’s report last week, he commented that this is about having accountability structures embedded throughout the system, because this is not something that the top of the NHS, the NHS chief executive, the Secretary of State or the ministerial team can control thr... Full speech
I thank the hon. Gentleman for his question. I know that this is an issue that he feels strongly about, and he has raised it with me before. The Minister of State for Health, my hon. Friend the Member for Bristol South (Karin Smyth), who is taking the NHS modernisation Bill through Parliament, is leading on the changes that we are seeking to make around HSSIP and the Care Quality Commission. I hear what the hon. Gentleman is saying, but my hon. Friend has clearly set out the Government’s rationa... Full speech
My hon. Friend is absolutely right to call this what it is in many cases, which is misogyny in maternity services, and to draw attention to the different impact on different mothers and the racial and ethnic inequality within the system. The anti-discrimination programme that I mentioned, which is being rolled out over the next year and a half, will be an important first step, but it cannot be the sum total of what we do to address discrimination and inequality. That will be a focus of the natio... Full speech
I welcome the Secretary of State’s statement and the work of Baroness Amos on this vital report. Disabled women are 44% more likely to suffer a stillbirth than non-disabled women. Drawing on the evidence session I chaired with our MaternAble campaign of disabled mothers, Baroness Amos’s report highlights the devastating discrimination and structural barriers that are causing such inequalities for disabled women, from devastating assumptions that we are not sexually active or capable of parenting... Full speech
On capital investment, I set out in my statement that we have announced an extra £41 million specifically to address critical safety issues in maternity and neonatal services. That funding is on top of the funding already in place, and it will help address those critical safety issues. The wider action plan will set out our overall approach. While funding will be a consideration in what the Government do, I again draw attention to the importance of deep-rooted issues such as culture, which must ... Full speech
My hon. Friend is right to again draw attention to the importance of accountability in making maternity services operate as they should. That applies to the racism, discrimination and inequality that it is important that we tackle, as she says. Ultimately, it is right that I as Secretary of State and all Government Ministers are held to account by Parliament for our actions in this space, but we also need to make sure that accountability is spread throughout the system. Our decision to extend th... Full speech
In the coming two weeks, I will be meeting the national taskforce, which I chair, to establish the scope and role of the new national maternity commissioner. I want to make sure that that is agreed with the taskforce. The taskforce will produce the action plan, which the commissioner will help to implement. I want to ensure that this is all done with the same principles in mind. The hon. Lady also raised an important point about not only mothers being ignored, which they are far too often, but s... Full speech
With permission, Madam Deputy Speaker, I shall make a statement on the national maternity and neonatal investigation. Less than a week ago, I stood at this Dispatch Box to respond to the report by Donna Ockenden that exposed devastating failings over more than a decade in Nottingham. As many right hon. and hon. Members rightly made clear following my statement, the shocking report into what had happened was far from the first: in 2015 we learnt of the failures at Morecambe Bay; in 2022 we were a... Full speech
My right hon. Friend is right to point to the impact that national triage standards can make by ensuring that when there are problems, the women concerned are seen earlier and those who need support can receive it at the right time, in order to prevent greater harm from occurring whenever possible. The national triage standards are currently being set out by NHS England, because that organisation still exists. The chief executive is meeting representatives of the trust today to begin the work of... Full speech
Yeovil hospital was included as part of the review after the temporary closure of its unit last year. Since then, families, frontline staff and I have repeatedly raised concerns with Government and NHS leaders about working culture, bullying, staffing levels and support. Today’s review backs that up, after months of feeling that our concerns have not been properly acted on. Can the Secretary of State detail what the Government are doing to improve staffing levels in rural maternity units and to ... Full speech
The hon. Lady is absolutely right to draw further attention to the issue of women being ignored in health services generally, but specifically when it comes to maternity services. That goes back to the culture in maternity services. It is a devastating conclusion to come to, but we see a culture there of misogyny, of women being ignored, and of their concerns not being listened to and acted on. We need to change that culture, and one of the first actions that we can take to do so is to have acco... Full speech
I thank the hon. Lady for her comments, and she puts it well when she talks about Baroness Amos’s investigation confirming our worst fears. I was shocked but not surprised, sadly, to read the investigation report. It was devastatingly familiar to read what it set out as being the failings across the country. The report’s recommendations will now become part of the work of the taskforce, which I chair, to produce the comprehensive action plan by the end of this year. My intention is that the task... Full speech
A retired paediatrician and constituent told me recently that after giving 50 years’ service to the children of the NHS, she was devastated by the treatment of mothers and babies and loyal staff, whose concerns are routinely ignored, as when Yeovil’s specialist baby unit was recently closed without notice. While I welcome the Government’s commitment to a new maternity commissioner, will the Secretary of State set out how the commissioner will intervene in a trust like Somerset, rather than simpl... Full speech
My hon. Friend is an incredibly powerful advocate on the issue of the discrimination that disabled mothers face in the health service, but particularly in maternity services. She has spoken about both the discrimination and the barriers to accessing care; she is right to say that those barriers are wide and systemic, and that needs to be addressed as part of the comprehensive action plan. I would be very happy for myself or a member of my ministerial team to meet my hon. Friend to discuss this i... Full speech
To deliver on this review’s recommendations in full will require serious capital investment. Just last week, we heard that St Helier, the hospital in my constituency, was considering closing its maternity unit altogether due to potentially unsafe pipework. Will the Government commit to reviewing the phasing of the new hospital programme, or at the very least providing the funds required to keep those buildings safe and open until the delivery of a new building? Full speech
The action plan, which will be developed through the taskforce that I chair-the commissioner will co-chair it when that position is established-will publish its national action plan by the end of this year. That will consider all the recommendations from Baroness Amos’s report, as well as Donna Ockenden’s reports. My hon. Friend makes a point that is worth drawing attention to, which is that many midwives and others working in maternity services do a really important job and work really hard to ... Full speech
Like others, I welcome this report. The Secretary of State referred to Dr Bill Kirkup, who resigned from the Amos review as an adviser because he felt that it was skirting around certain birthing ideologies and caesarean targets. The Secretary of State said that “staff shortages can have a dangerous impact”, and indeed they can. Although he and Baroness Amos refer to culture, a lot of that culture is to do with budgetary and other pressures that result in members of staff on the frontline being ... Full speech
My hon. Friend is right to draw attention to the disparity in what black women and their babies experience in the health service and the extra risks they face, particularly in maternity services. The taskforce will produce a comprehensive action plan by the end of the year, and I anticipate that it will include metrics for delivery and ways of monitoring progress. I will make sure that my hon. Friend’s comments are fed into the work of the taskforce. Full speech
I pay tribute to Baroness Amos for the report she has published, which lays bare the scale of racism and discrimination in maternity and neonatal care. This is not a surprise to anyone; it is an issue that I and many other hon. Members in this place have been raising for years. I welcome the recommendation to root out racism and discrimination in these services, but more broadly, we all know that structural inequalities exist across the NHS, whether we like it or not, and we need to hold those r... Full speech
I call the Chair of the Health and Social Care Committee. Full speech
I thank my right hon. Friend for her comments and agree about how shocking the failures in maternity services are, particularly because these failings and the failure to listen to women happens at a point when they are at their most vulnerable. It is at that moment when they are let down. When they need the NHS the most is when the NHS fails them, and that is one aspect of this that makes it truly devastating. My right hon. Friend also rightly highlights the impact on black women and their babie... Full speech
The hon. Gentleman raises an important point about ensuring the right levels of staff and training, and about ensuring that the right structures are in place. I know from seeing Baroness Amos’s report, and from the recommendations in Donna Ockenden’s report last week, that those questions will be central to the work of the taskforce in developing the national action plan. As I have said a few times today, it is not the case that there are simply one or two levers that we need to pull, or actions... Full speech
I very much welcome the report and Baroness Amos’s work to highlight the failings across our maternity system. It is pure and utter medical misogyny that has led us here. The value that we place on the lives and experiences of women has been brought to the fore, and it is very, very low. The throughline of this report and the ones before it is that women’s voices were not heard, their pain was not believed, and their experiences were completely and utterly disregarded. That must change. I would ... Full speech
I call the Liberal Democrat spokesperson. Full speech
I absolutely agree with the hon. Lady that I, as Secretary of State, must be held to account, and that is the role of this House. I will take that away and work out the best way of making sure that that happens, on a basis and to a timetable that people can understand, because I would like to make sure that I am held to account for delivering the whole action plan in the right way. I will take that point away and come back to the hon. Lady with an update. Full speech
My hon. Friend is right to point to the importance of the Hillsborough law, because it will enable greater accountability and justice across society, as well as being crucial for future maternity investigations. That is why one of the commitments I made last week following Donna Ockenden’s report was to apply the duty of candour, which the Hillsborough law will enable, to all future maternity investigations, so that never again can we have a situation where senior clinical leaders choose not to ... Full speech
I hugely welcome the report and join in the thanks to all those who made it possible, but most fundamentally the families who shared their experiences and showed extraordinary courage through the whole process. Many of those stories were shared with us in the all-party parliamentary group on baby loss, and I assure those families that we will carry on listening to and being a voice for them through this process. The reports makes many powerful recommendations-I welcome the action plan and the ma... Full speech
The Secretary of State will know that many women are never more vulnerable than in childbirth. It is about not just the vulnerability, but the horror of what women and their babies are exposed to in childbirth. We see inquiry after inquiry, and nothing seems to improve. Very many of those who suffer during childbirth are black women and their babies. The Secretary of State said himself that “Black babies are still more than twice as likely to be stillborn than white babies, and black women are a... Full speech
The Secretary of State’s announcement of 1,000 extra midwives is welcome, even if the funding is temporary. However, this is a review of maternity and neonatal services. In Baroness Amos’s review of Sussex, she noted that in the 12 months ending in October 2025, only 50.1% of shifts at the Royal Sussex county hospital in Brighton were staffed according to British Association of Perinatal Medicine guidelines. What provision is the Secretary of State making to ensure that neonatal staffing is safe... Full speech
The lack of national maternity triage standards has been of huge concern to a number of my constituents, in some cases through bitter and heartbreaking experience. The Secretary of State said that NHS England would be responsible for rolling out and monitoring triage standards. Will that responsibility pass into his Department by April next year, and how will he ensure that those standards are genuinely implemented in every trust? Full speech
I echo what was said by my colleague from the Health and Social Care Committee, the hon. Member for Oxford West and Abingdon (Layla Moran). Baroness Amos pointed to workforce challenges and their impact on care and safety, and she noted that 67% of midwives reported burnout. Meanwhile, a General Medical Council survey found that 63% of obstetrics and gynaecology trainees had a high or very high workload. That is higher than the 42% average. The workforce plan has to address those problems-but wi... Full speech
I thank the Secretary of State for making this statement. I pay tribute to the noble Baroness Amos for her work and the care and dedication with which she has produced this report, and to the many women who came forward with their testimonies. I think back to the concerns that I raised just over nine years ago, when I was giving birth to my second son. Nine years on, women are still being dismissed, still not being listened to and still being silenced when they raise those valid concerns. I pay ... Full speech
Recommendation 3 of the report calls for improvements to how the system responds when something goes wrong, including providing a sincere apology. Will the Secretary of State apologise now to my constituents Charlotte and James, who lost their baby Norah at Winchester hospital, and to the thousands of families who have suffered the loss of a baby due to systemic failures in NHS maternity care? Full speech
I am not a doctor, but thank you so much, Madam Deputy Speaker. Perhaps I am a doctor from the university of life-who knows? I pay tribute to Baroness Amos for this excellent report, and to my right hon. Friend the Member for Ilford North (Wes Streeting) for commissioning it. It is a remarkable piece of work. It follows on from Ockenden, and the report on black maternal health done by my Health and Social Care Committee-its Chair, the hon. Member for Oxford West and Abingdon (Layla Moran), sits ... Full speech
In describing the role of the commissioner, the hon. Lady is right to emphasise that it cannot all be on one person. The commissioner is a vital role, and it being on a statutory basis will give the position real weight within the system to hold the system to account and help the Government to ensure the implementation of the comprehensive national action plan. But she is right to say that accountability has to include the Secretary of State and the Prime Minister, because it is a duty that we a... Full speech
I thank the shadow Secretary of State not only for his questions, but for his tone and approach. When I gave the statement about Donna Ockenden’s report last week, we all agreed that the responsibility to deliver real change is shared by everyone in this House, so I appreciate his approach. The right hon. Gentleman asked about the investigations in Leeds and Sussex, to which Donna Ockenden will be turning her attention over the rest of this year. It might be helpful for the House to understand t... Full speech
This report is welcome, but that does not make its existence any less tragic. Far too many mothers and babies have been failed, including mothers like my constituent Amie, who late last year was turned away repeatedly, despite reporting reduced movements. Her baby Seren was born stillborn. The NHS spends almost as much on clinical negligence payouts as it does on maternity care itself. Can the Secretary of State update us on progress made following the Lock review into clinical negligence? It is... Full speech
I thank my right hon. Friend for his comments, and again put on record my thanks and tribute to him for having initiated the investigation that Baroness Amos published today. He has been a committed champion of change in maternity services in this country. I could not agree with my right hon. Friend more about the importance of accountability in culture change. Without accountability, we will not have culture change across maternity services, and the culture of cover-ups will continue. Senior cl... Full speech
I start by commending my right hon. Friend on his thoughtful and considerate approach to this investigation and other matters during his time in office. He rightly spoke about culture, and others have spoken about ideology. Does he agree that the only ideology that matters as we try to change this culture should be rooted in science and evidence? Will my right hon. Friend therefore consider ensuring that women in maternity are the first in line to be the beneficiaries of that science and evidenc... Full speech
My hon. Friend draws out an important point: a key part of developing the national action plan is to ensure we have the right metrics and mechanisms for monitoring its implementation and the right structures in place to make sure it is implemented across all trusts. In working with members of the taskforce, I will ensure that those accountability mechanisms for the delivery of the plan are in place, because I have spoken many times today about the importance of recommendations not sitting on she... Full speech
I was incredibly sorry to hear about my hon. Friend’s constituent Amie, who was turned away repeatedly from services despite asking for their help. We have heard that story far too many times as part of the work that Baroness Amos and Donna Ockenden have done and from our constituents. My hon. Friend is right to point out the amount of money that goes on clinical negligence, rather than making sure that services are better in the first place, which would avoid the need for clinical negligence pa... Full speech
Will the Secretary of State keep an open mind as to whether it is right to abolish the Health Services Safety Investigations Body, which was specifically designed to provide for a duty of candour? Clinicians would be obliged to give evidence to HSSIP; they could not refuse, and there would be criminal penalties if they did. As we have already established, the duty of candour, as conceived in the Hillsborough law, does not work, and I suspect there will be no improvement unless HSSIP is allowed t... Full speech
I, too, thank Baroness Amos, her team and, most especially, the families who so bravely gave the evidence that has formed this report. Further to the conversation about accountability, the Secretary of State will have noticed that some families are concerned that the commissioner is just one person, and that there is too much for them to do. Can he make clear that the buck stops with him and, indeed, the PM, and that he will not let go of this? The commissioner will report every six months to th... Full speech
I welcome Baroness Valerie Amos’s review, and I thank her and her team for their commitment to this vital work. Once again, this review confronts us with a very uncomfortable but real truth. The reality is that this inquiry and the Donna Ockenden inquiry did not come about because of a system, NHS England or a regulatory authority; it came about because families have to keep on speaking up, over and over again, about one of the most horrific and traumatic things ever to happen. All the while, th... Full speech
I strongly agree with the comments of the former Secretary of State, the right hon. Member for Ilford North (Wes Streeting), about the need for getting the culture right with accountability. When I was Secretary of State, we passed the duty of candour regulations. They were supposed to make it-well, they do make it-a criminal offence for trusts not to tell the truth to families when a tragedy has happened. Yet to this day, trust lawyers advise doctors, nurses and midwives not to be open about wh... Full speech
May I also add my thanks to the Secretary of State, to Baroness Amos and her team, and to the families that have relived the pain of their experiences to bring about this report? But the Amos report tells us little that we did not already know-indeed, it confirms our worst fears. Maternity services in England are fundamentally broken with the cost of political neglect being paid in trauma, injury and lost lives. Figures revealed by the Liberal Democrats in the last week show that the first quart... Full speech
I, too, put on the record my thanks to Baroness Amos and her team, and to the families who relived their pain so that this report could exist-they are the real heroes here. I welcome the report, as well as the announcement of the new maternity and neonatal commissioner. It is vital that the report recognised structural racism, but that will mean nothing unless it leads to national standards that tackle inequality and deliver high-quality care for every mother and their baby. I note that the repo... Full speech
I thank the hon. Lady for welcoming the additional 1,000 positions to make sure that newly qualified midwives can find a way to contribute to the NHS. She raises staffing and training, as other Members have rightly done. The taskforce will consider questions about ensuring that we have the right staffing in place, with the right training to support it, ahead of the publication of the national action plan at the end of the year. Full speech
I will take away the right hon. Gentleman’s suggestion and think on it, because it is critical that we have accountability. As I said in response to earlier questions, I find the decision of senior clinicians not to take part in the Nottingham inquiry utterly unacceptable, and incomprehensible on a personal level. We must ensure that that never happens again. Full speech
I welcome Baroness Amos’s investigation, which has shone a light on the fact that these failings in maternity services are not isolated to one hospital or another, but exist across the piece. The Secretary of State rightly identifies that culture is at the centre of this issue, and that we must listen to the voices of women and of whistleblowers. That applies not just to maternity services, but across the NHS and, indeed, in public life more widely. The Secretary of State has spoken about accoun... Full speech
My hon. Friend asks about the timing, and the process for establishing a commissioner. As a first step, in the next two weeks, I will meet members of the taskforce to agree the scope, and a detailed role for the commissioner, because I want that scope and role to be agreed with them, given that they will be developing the national action plan. We then need to get the commissioner on a statutory basis, and I want to do that as quickly as possible. I am keen to look for options to do that through ... Full speech
The hon. Gentleman is right to draw attention to the impact that bullying and a poor working culture can have on maternity services. That focus on culture and on what we can do to change it will be a key part of the national action plan that the taskforce will develop. We want to make sure not only that staffing levels are correct and that staff have the right training, but that different members of staff work together across different disciplines and roles, because that is one way to make sure ... Full speech
Order. Before I call the next Member, I wish to say three things. First, the Secretary of State for Defence will commence his statement at 2.30, so time is limited; Members may help each other if they ask short questions. Until then, the Macmillan Room in Portcullis House and Committee Room 7 are available as reading rooms for the defence investment plan. The plan will be made available from the moment that the Secretary of State for Defence begins his statement at 2.30. Full speech
I thank my hon. Friend for his emphasis on the need for us to tackle the deep-rooted cultural problems in maternity services. He talks about how the only ideology that we should follow should be based on science and evidence. I agree with him on the importance of science and evidence, and of making sure that women are aware of the risks and benefits of the different options available to them, so that they can make informed choices. I add that the only ideology I would be comfortable signing up t... Full speech
Our APPG on birth trauma report in 2024 was the first in Parliament on that subject. We heard from more than 1,300 women and families. The report was titled, “Listen to Mums”. I am glad that an independent maternity commissioner will finally be implemented, after our years of calls for one. Bill Kirkup’s headline finding in his 2023 review of east Kent was also that we should listen to women. The Health Secretary has repeated the importance of listening to women-the mothers, midwives, and expert... Full speech
The Secretary of State, like countless other Ministers over the years, has stood at the Dispatch Box to outline and apologise for yet another state cover-up. Can we agree that enough is enough? Will he personally intervene and beg the Prime Minister to pass the Hillsborough law in full-it has been promised to us on numerous occasions-before summer recess and end this culture of cover-ups? Full speech