James Murray
MP for Ealing North · Labour (Co-op) · United Kingdom
“I wonder whether any other Members might say that they have the most pubs in their constituency, or whether the hon. Lady has done her research. [Interruption.] I hear her saying that hers are the best pubs, a claim that even more Members may challenge in the Chamber. Although the hon.”
“The hon. Gentleman has some cheek, given the number of pubs that closed when his party was in government. The Labour party is making sure that the business rates system is set right for the future.”
“I think the hon. Gentleman’s point is that the price of fuel is linked to international events, which, as I said earlier, I very much agree with. That is why it is important that we de-escalate the situation in the strait of Hormuz, which is the best way to bring down the cost of fuel.”
“I know my hon. Friend is a great champion of pubs in her constituency. In fact, she has brought together people for her pub politics events, including at the Willy Wicket, the Beaufort Arms, the Baileys Court Inn—which I have been to—and the White Lion, where people come to talk about issues that matter to them.”
“I thank the hon. Gentleman for talking about the Station House in his constituency; I am sure we all have pubs in our own neighbourhoods that we feel are at the heart of the local communities that we represent. The 20% business rates cut that we announced was a down payment on further reform.”
“I agree with the hon. Lady about the importance of providing breathing space for families, which is a priority for us as a Government, and she mentioned her plans. I have set out what we have done since the general election to reduce fuel prices by 11p per litre compared with what they would have been otherwise.”
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“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 shelves. We need to ensure we have the structures in place such that the actions in the national action plan are implemented, we can see they are being implemented, and we can give people confidence that that is the case.”
“The commissioner role is being established to support the effectiveness of the work we are seeking to do as a Government to implement the national action plan, but crucially, when accountable politicians are taking decisions, the commissioner will be a voice for women in the system. I have heard so many times that women’s voices are not being heard in the healthcare system, particularly when things go wrong and women have concerns in maternity services. This commissioner will be a way of making sure those voices are right at the heart of decision making.”
“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 all hold as MPs, that the Government hold and that I hold as Secretary of State, and the Prime Minister ultimately holds that responsibility too. It is not in any sense intended to be a passing of responsibility to a commissioner.”
“That is evidenced by the fact that 9,000 members of staff came forward to give evidence in Baroness Amos’s investigation—they are concerned, and they want to see change as well. While this is, of course, primarily about women and their babies and families, staff also have a really important voice in this, and we need to improve the system so that they can make their contribution as well.”
“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 provide excellent care to women. That is not to diminish the scale of the failings, but it is to give the right perspective on all those midwives who do a really important job and work hard to care for women and their babies.”
“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.”
“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 national taskforce, as will—to repeat a point many Members have rightly made—accountability, because it is only by embedding accountability throughout the system that we can be truly confident of change.”
“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 that we need to take, to bring about change; however, the issues that the hon. Gentleman mentions are clearly central to what we need to do.”
“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.”
“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.”
“It is worth emphasising that the role of the commissioner will be to implement the national action plan, so work on developing the plan and on establishing the commissioner will begin immediately. When the commissioner is appointed, they will have a role in implementing the national action plan. The issue is not simply about developing a national plan; it is about ensuring that it gets implemented, and that we hold trusts and other organisations across the system to account.”
“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 the Health Bill, but that will obviously be subject to discussions with the usual channels. Once that is in place, we can appoint the commissioner as quickly as possible.”
“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 accountability. We must ensure accountability, through the duty of candour that we have discussed, and through other actions that we can take to enhance accountability throughout the system. That is a critical first step in ensuring that we change the culture.”
“Friend is absolutely right; this must be about fundamental reform to all parts of the system, including the regulators, which have let women down far too often.”
“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 responsibility to ensure that they do not have to drive these changes alone. We as MPs, Government Ministers and Secretaries of State support families in the drive for accountability, justice and change. My hon.”
“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 rationale for the changes we are seeking to making and what they will accomplish.”
“More broadly, the national action plan, which we will publish by the end of the year, will explain exactly how we will embed accountability for racism and discrimination throughout the system.”
“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 the anti-discrimination programme across all trusts by the end of 2027 is an important first step in making sure that all trusts are held accountable for tackling discrimination and racism where it exists.”
“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. The hon. Lady’s constituents Charlotte and James and their baby Norah are just one more example of families being let down by NHS maternity services. The responsibility to do something about it weighs heavily on all of us, and on me as Secretary of State.”
“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 issue in more detail.”
“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.”
“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.”
“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 be addressed as part of the plan.”
“The single patient record can be of real benefit and make a difference, particularly in maternity services, and it will be enabled by the NHS modernisation Bill that is going through Parliament. I want to make sure that the single patient record is available to maternity services as quickly as possible. I am happy to share a copy of the report with the Scottish Government.”
“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 to is one that says that women must be listened to. That is a principle that I think we can all agree on, and we should make sure that it is embedded in our maternity services. My hon. Friend mentions investment in technology, including the single patient record.”
“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.”
“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 payouts. I have met David Lock KC to discuss his ongoing work on that issue, and I will be working with him closely on it in the months ahead.”
“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 that the service improves.”
“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 participate and choose to avoid accountability.”
“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 staff being ignored. A few Members have made that point today, and it bears repeating. We know that 9,000 staff contributed to Baroness Amos’s report, which underlines the fact that they want a better maternity service, too.”
“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 rolling out triage standards across all the different trusts. When NHS England becomes part of the Department for Health and Social Care, we will of course continue to monitor that, and the taskforce will also consider it as part of its national action plan.”
“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.”
“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.”
“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.”
“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.”
“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.”
“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 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.”
“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.”
“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.”
“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.”
“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?”
“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.”
“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 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.”
“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.”
“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.”
“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.”
“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.”
“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.”