from early in the morning. our correspondent tomos morgan is in mold in north wales for us. tomos, what more can you tell us? the graters have been out in force on the roads, the warning signs have been out on the dual carriageway is under all schools here in flintshire are due to be closed tomorrow as a precaution for these wintry conditioners. so where these amber warnings will be taking place tomorrow, between 8am and mid afternoon across much of north wales and north—west shropshire there is due to be an amber warning for snow and ice, from mid to dash from midday until early evening there is an amber weather warning for heavy snow from the pennines and the peak district and there could be between four and six inches of snow in both areas, up to ten inches on higher ground. the met office has said there will probably be some travel

disruption tomorrow with the icy conditions, could be issues on rail services too because of the cold weather and they have told people not to drive unless they really, really have two tomorrow. the higher you are, the more likely you are to see some of the white stuff around you. tomos, thank you. this image of a young polar bear asleep on an iceberg has won the wildlife photographer of the year people's choice award. the man who took it has told us all about how he got that image. the population of sudan needs humanitarian assistance. 25 million people — far too this programme continues on bbc one. is the shadow cabinet at war with itself?

it's three years since the shadow chancellor rachel reeves announced the £28 billion green bonanza, boasting it would make labour the greenest government in history. since then it's been going and going and now it appears gone. we'll be asking one of tony blair's former senior operatives and the leader of a labour think tank if keir starmer is right to be cautious, orflaking on bold promises. also tonight, antony blinken tells benjamin netanyahu there still a chance for a deal over gaza, and warns him about inflaming tensions. what's behind the israeli leader's demand for total victory? they would like to prolong the war, what they say, until there is complete victory, and the destruction of hamas, and they won't accept any ceasefire even for the exchange of the hostages. and when the birth of a baby should

be a time of great celebration, we're joined by parents whose experience at the hands of maternity service was, instead, tragic. they are calling for a national investigation into maternity care. good evening. it's been a day of high political turbulence for both rishi sunak and now tonight keir starmer. for his part the prime minister is being accused of making dehumanising comments about trans people by the father of the murdered teenager brianna ghey. peter spooner has demanded the pm apologise for his comments. the turbulence around the leader of the labour party tonight is squarely on policy and a key policy at that. it has emerged his party will announce tomorrow that it is abandoning its plan to invest £28 billion in green prosperity if it wins the general election that is expected later this year. this, just days after the cbi tweeted that the green prosperity plan is core to uk labour's economic strategy. presumably that was with its financial offering intact.

nick is here. what's happened 7 this is the long and increasingly inevitable demise of what had been a defining policy for sir keir starmer. tomorrow would labour leader will confirm that he is abandoning that specific 28 billions bound figure but not resigning from his overall commitment to deliver what he calls clean power. i was talking to one of his allies this afternoon and they told me this is an albatross around our necks, we won't go into an election with that. what is so interesting about all this is just until a few days ago keir starmer was standing by that £28 billion figure. this is what he told times radiojust £28 billion figure. this is what he told times radio just this week. we're going to need investment. that's where the 28 billion comes in. that investment that's desperately needed for that mission. and i've been unwavering in relation to the mission. supporters thought the policy was

bombproof because it had been tweaked since the shadow chancellor unveiled it in 2021 and that original plan was to spend £28 billion a year to achieve green power by 2030 and the changes since then had meant that £28 billion spending target wouldn't be met on day one, the first year of a labour government, it would be ramped up and meant midway through the parliament. the second point was the debt rule came first and that would restrain it but critics in the shadow cabinets said this will not be bombproof in a general election. the tories would say that is £28 billion of tax increases, of borrowing. they said think of that 1992 general election and the tory tax bombshell campaign and they said there would be more of this. our big commitment is our climate investment. - we pledged £28 billion. £28 billion a year. £28 billion. 28 billion that we will borrow.

where does this leave the cares to? bruised because he really believes in this policy and also bruised because he feared a change would make him weak and open to that tory flip—flop charge. it may also change keir starmer�*s relationship with ed miliband and kier starmer was instrumental, sorry, ed miliband was instrumental, sorry, ed miliband was instrumental in getting kier starmer as an mp in 2015. ed miliband was the key driver behind this policy and i was talking to a shadow can tally of kier starmer it was furious about what they saw a fundamental flaw of a really good policy and the problem was it wasn't branded by what it would do, green power by 2030, it was branded by what it would cost, £28 billion a year and they said they were two very simple expirations for what went wrong, ed miliband. the two big questions to my door, does this show that kier

starmer has moved definitively from planet ed miliband to planet tony blair who of course went into that 97 election saying we will take two story spending commitments for the first two years, and does it show caution first and can you win an election on caution first if there is a yearning in the country for change? i'm joined now byjohn mcternan who served as tony blair's director of political operations and byjosh simons from the labour together think tank. john mcternan, dithering for a long time, was he right to axe that £28 billion figure?— time, was he right to axe that £28 billion figure? probably most stupid decision the labour— billion figure? probably most stupid decision the labour party _ billion figure? probably most stupid decision the labour party has - billion figure? probably most stupid| decision the labour party has made. what would tony blair have done? i don't care because he was the leader in the 20th century, kier starmer will be the prime minister in a 21st—century, this is a decision we have to make now to decarbonise our economy. it is one which stands for a purpose, a grand purpose, great parties have great causes. if you

don't have a great cause, you want to change from this government, but what is the change labour offers? very disappointing. what what is the change labour offers? very disappointing.— what is the change labour offers? very disappointing. what will be on the side of the _ very disappointing. what will be on the side of the election _ very disappointing. what will be on the side of the election buzz, - very disappointing. what will be on | the side of the election buzz, would it have been cumulatively as it would have been over the lifetime apartment may be?— would have been over the lifetime apartment may be? should be there is more homes. — apartment may be? should be there is more homes, great _ apartment may be? should be there is more homes, great british _ apartment may be? should be there is more homes, great british energy, - more homes, great british energy, the wealth fund, all those elements, and i heard what nickjust said, it wasn't ed miliband that announced £28 billion, it was rachel reeves. josh, right to do it?— josh, right to do it? absolutely. i think of this _ josh, right to do it? absolutely. i think of this like _ josh, right to do it? absolutely. i think of this like when _ josh, right to do it? absolutely. i think of this like when you - think of this like when you are thinking — think of this like when you are thinking of buying a house and you -et thinking of buying a house and you get to— thinking of buying a house and you get to go— thinking of buying a house and you get to go on a mortgage calculator and you _ get to go on a mortgage calculator and you plug in your income and it tells _ and you plug in your income and it tells you _ and you plug in your income and it tells you what your interest rate is and out _ tells you what your interest rate is and out pops a number and it tells you what _ and out pops a number and it tells you what you can borrow. what labour did as _ you what you can borrow. what labour did as they— you what you can borrow. what labour did as they started with the number they could — did as they started with the number they could borrow. the interest rate has changed, the income... they could borrow. the interest rate has changed, the income. . .- has changed, the income... was it foolish to do _

has changed, the income... was it foolish to do in _ has changed, the income... was it foolish to do in the _ has changed, the income... was it foolish to do in the first _ has changed, the income... was it foolish to do in the first place? - has changed, the income... was it foolish to do in the first place? it i foolish to do in the first place? it is not howl foolish to do in the first place? it is not how i would have started doing _ is not how i would have started doing policy, iwould have is not how i would have started doing policy, i would have started by arguing — doing policy, i would have started by arguing for the principle that you need — by arguing for the principle that you need to borrow to buy a house, to get _ you need to borrow to buy a house, to get a _ you need to borrow to buy a house, to get a roof — you need to borrow to buy a house, to get a roof over your head and that is— to get a roof over your head and that is what keir starmer has been saying. _ that is what keir starmer has been saying. it — that is what keir starmer has been saying. it is— that is what keir starmer has been saying, it is something he will argue — saying, it is something he will argue for— saying, it is something he will argue for the.— saying, it is something he will argue for the. saying, it is something he will araue for the. , ., ., ,, argue for the. does it not make him look like mr— argue for the. does it not make him look like mr cautious? _ argue for the. does it not make him look like mr cautious? this - argue for the. does it not make him look like mr cautious? this was the | look like mr cautious? this was the big bold policy announcement? the tories love this flip—flop line but we pulled — tories love this flip—flop line but we pulled the voters all the time, and they— we pulled the voters all the time, and they have not noticed the flip and they have not noticed the flip and i_ and they have not noticed the flip and i have — and they have not noticed the flip and i have not noticed the flop. not et. the and i have not noticed the flop. iirrt yet. they might notice a very big flip. yet. they might notice a very big fli -. , yet. they might notice a very big fli -. y ., . ., ,., flip. they will notice the labour stance when — flip. they will notice the labour stance when we _ flip. they will notice the labour stance when we get _ flip. they will notice the labour stance when we get to - flip. they will notice the labour stance when we get to the - flip. they will notice the labour - stance when we get to the election. the first— stance when we get to the election. the first question will be, what remains, as it clean steel, insulating houses, what stays and what goes? the insulating houses, what stays and what goes?— what goes? the mission stays. green ower b what goes? the mission stays. green power by 2030 _ what goes? the mission stays. green power by 2030 stays. _ what goes? the mission stays. green power by 2030 stays. it _ what goes? the mission stays. green power by 2030 stays. it would - what goes? the mission stays. green power by 2030 stays. it would be - what goes? the mission stays. green | power by 2030 stays. it would be mad for a credible labour government to stand _ fora credible labour government to stand in_ for a credible labour government to stand in front of the british public and say— stand in front of the british public and say we — stand in front of the british public and say we will stick to a number

come _ and say we will stick to a number come what — and say we will stick to a number come what may to achieve that mission — come what may to achieve that mission. . , come what may to achieve that mission. ., , , ., mission. i have seen loads of ollin: , mission. i have seen loads of polling. focus _ mission. i have seen loads of polling, focus groups, - mission. i have seen loads of polling, focus groups, focusl mission. i have seen loads of. polling, focus groups, focus on mission. i have seen loads of- polling, focus groups, focus on tory 2019 voters and i have seen no evidence that any of them care about the size of the money. they understand investment needs to a better future and that investment leads to lower bills for them. there is a huge fear that labour will say anything and do anything to get into power and that is one of the most dangerous accusations you can make against a politician.— against a politician. laura trott the chief secretary _ against a politician. laura trott the chief secretary to - against a politician. laura trott the chief secretary to the - against a politician. laura trott . the chief secretary to the treasury said labour has no plan for the uk, that will stick.— that will stick. the treasury have been telling _ that will stick. the treasury have been telling the _ that will stick. the treasury have been telling the financial - that will stick. the treasury have been telling the financial times, j been telling the financial times, what _ been telling the financial times, whatjeremy hunt is pined to do at the budget is max out the fixed school — the budget is max out the fixed school headroom and so what rachel reeves _ school headroom and so what rachel reeves is thinking is can i stand in front— reeves is thinking is can i stand in front of— reeves is thinking is can i stand in front of the — reeves is thinking is can i stand in front of the british people and say you know — front of the british people and say you know what i will do, i will stick— you know what i will do, i will stick to— you know what i will do, i will stick to this number that we announced three years ago regardless. it announced three years ago regardless.— regardless. it is also about economic—

regardless. it is also about economic probity, - regardless. it is also about economic probity, you - regardless. it is also about| economic probity, you have regardless. it is also about - economic probity, you have two things here, only last week keir starmer holds a business meeting at the oval, what will business make of it, then the cbi say green prosperity is the core of the uk labour economic strategy. the green prosperity is not motherhood and apple pie, it demands investment and thatis apple pie, it demands investment and that is what they were talking about. �* ., , ., , that is what they were talking about. �* ., ,._ ., j~ about. the cbi did not say that 28 billion is a number— about. the cbi did not say that 28 billion is a number that _ about. the cbi did not say that 28 billion is a number that we - about. the cbi did not say that 28 billion is a number that we know. about. the cbi did not say that 28 l billion is a number that we know for sure is— billion is a number that we know for sure is the — billion is a number that we know for sure is the number required. was the number was — sure is the number required. was the number was a — sure is the number required. was the number was a mistake? _ sure is the number required. was the number was a mistake? of— sure is the number required. was the number was a mistake? of course - sure is the number required. was the | number was a mistake? of course and the should number was a mistake? of course and they should have _ number was a mistake? of course and they should have got _ number was a mistake? of course and they should have got off _ number was a mistake? of course and they should have got off it _ number was a mistake? of course and they should have got off it in - they should have got off it in october— they should have got off it in october 2022 when kwasi kwarteng and liz truss _ october 2022 when kwasi kwarteng and liz truss crash the budget, that was the time _ liz truss crash the budget, that was the time to— liz truss crash the budget, that was the time to pivot. it has been badly handled _ the time to pivot. it has been badly handled now and the dividing line that laura — handled now and the dividing line that laura trott is trying to create. _ that laura trott is trying to create, the issue is not no plan versus— create, the issue is not no plan versus the _ create, the issue is not no plan versus the plan, it is the government has their own plan. labour— government has their own plan. labour has _ government has their own plan. labour has to have a plan and offer hope _ labour has to have a plan and offer hope it—

labour has to have a plan and offer hope. it goes back to offering hope and offering change and that is what progressive parties have to do. but where progressive parties have to do. where does progressive parties have to do. pm where does he get back to add to this in terms of the green upper? i think where you get back to is the announcement, what is the detail of great _ announcement, what is the detail of great british energy, the detail of the wealth fund, the detail of the warm _ the wealth fund, the detail of the warm homes programme because people tet warm homes programme because people get that— warm homes programme because people get that of— warm homes programme because people get that of their house is insulated they will— get that of their house is insulated they will cut their electricity or as they will cut their electricity or gas bills— they will cut their electricity or gas bills permanently so you have to tet gas bills permanently so you have to get back— gas bills permanently so you have to get back to _ gas bills permanently so you have to get back to that for real punters, 'obs get back to that for real punters, jobs and — get back to that for real punters, jobs and prices. in get back to that for real punters, jobs and prices.— jobs and prices. in terms of the shadow can _ jobs and prices. in terms of the shadow can there _ jobs and prices. in terms of the shadow can there will— jobs and prices. in terms of the shadow can there will be - jobs and prices. in terms of the shadow can there will be a - jobs and prices. in terms of the shadow can there will be a lot l jobs and prices. in terms of the | shadow can there will be a lot of unhappy people. shadow can there will be a lot of unhappy people-— shadow can there will be a lot of unhappy people. there will be some unha-- unhappy people. there will be some unhappy and — unhappy people. there will be some unhappy and some _ unhappy people. there will be some unhappy and some happy _ unhappy people. there will be some unhappy and some happy and - unhappy people. there will be some i unhappy and some happy and john has spelt out beautifully exactly where they will get to, move beyond the arbitrary number and start talking about what the policy... arbitrary number and start talking about what the policy. . ._ about what the policy... and an election is _ about what the policy... and an election is likely. _ about what the policy... and an election is likely. we have - about what the policy... and an i election is likely. we have months and tomorrow _ election is likely. we have months and tomorrow we _ election is likely. we have months and tomorrow we learn _ election is likely. we have months and tomorrow we learn an - and tomorrow we learn an announcement and the important point is if rachel reeves were to stand before the public and say don't worry, we will borrow this amount of

money, what made they would think she is crazy and instead she will say what we are going to do is inside your home. 50 say what we are going to do is inside your home. so everything she said before was _ inside your home. so everything she said before was wrong. _ inside your home. so everything she said before was wrong. people - inside your home. so everything she said before was wrong. people will. said before was wrong. people will see that everything that went before was one of most public are not paying attention. wow. they have other things to do. they will look and think is other things to do. they will look and thin r , .,, . other things to do. they will look andthin , .,. , other things to do. they will look andthin , other things to do. they will look andthint , .,. , ., and think is as a credible offer for government? _ and think is as a credible offer for government? the _ and think is as a credible offer for government? the public- and think is as a credible offer for government? the public are - and think is as a credible offer forl government? the public are pretty clever but thank _ government? the public are pretty clever but thank you _ government? the public are pretty clever but thank you very - government? the public are pretty clever but thank you very much - clever but thank you very much indeed. tomorrow the chief executive of an under—fire nhs trust faces a meeting of his board — as an independent report questions whether the organisation's senior leadership should even continue in theirjobs. police are investigating 105 cases of alleged medical negligence at university hospitals sussex nhs foundation trust. and newsnight has been reporting on concerns there for months. joe is here to explain. this report from the royal college of surgeons into general surgery at one of the hospitals is pretty damning, in particularabout

one of the hospitals is pretty damning, in particular about senior leadership. it says there are, there seems to be a culture of fear amongst staff when it came to the executive leadership team, reports of bullying by the executive leadership team when staff were told to sit down, shut up and listen. in the surgery department there are reports that two trainees were physically assaulted by a consultant surgeon in theatre during surgery. high mortality rates for certain surgeries and a high number of complaints. on page 28 amongst recommendations this key sentence. the local mp caroline lucas seems pretty angry. i have been increasingly concerned about reports that i have been receiving from constituents, from whistle—blowers and, of course, this royal college of surgeons report about a really toxic culture that is coming right from the very top of the royal sussex. and frankly no one should be facing intimidation or bullying

anywhere in the nhs. i have raised my concerns on numerous occasions with the leadership, with the chief executive in particular, and i am simply not reassured that the issue is being taken seriously enough and that it is happening fast enough. what are the trust saying? josh findlay knows _ what are the trust saying? josh findlay knows the _ what are the trust saying? jrrsn findlay knows the board what are the trust saying? it?“ findlay knows the board meeting tomorrow could be tough so he has released a statement ahead saying he commissioned the report, it makes tough readings but it gives them the confidence they have the team and write plans in place, investing more in stock, recruiting, more and long—term problems can't be solved overnight but you have this critical report, ourjournalism, the investigation and the coc report we are expecting in the coming days, which means that board meeting tomorrow could be tense. it is due tomorrow could be tense. it is due to last three and a half hours and it is public so you can watch it online. . ~ it is public so you can watch it online. ., ~' ,,

are we reaching a point in the israel—gaza conflict where, after of thousands and thousands of deaths, and widespread destruction of gaza itself, the faint outline of a deal is starting to becoming visible, or has benjamin netanyahu stopped that dead in its tracks tonight? the us secretary antony blinken is in tel aviv, talking to the israeli prime minister, who opposes hamas's proposal for a full withdrawal of israeli forces from gaza and an end to the war after three 45—day periods of truce. so, who in israel has the whip hand? here's joe inwood. it is often said that all wars end with negotiations. if that is true, benjamin netanyahu's response to hamas's demands suggest the war in gaza has a way to go. translation: ,, ., ., ., ,�* , translation: surrendering to hamas's delusional demands _ translation: surrendering to hamas's delusional demands will _ translation: surrendering to hamas's delusional demands will not _ translation: surrendering to hamas's delusional demands will not only - translation: surrendering to hamas's delusional demands will not only not. delusional demands will not only not lead to the release of hostages but will bring another massacre. i5 will bring another massacre. is your's prime minister has said he wants to achieve total victory, but

he faces pressure from all sides, some calling for a harder line, others for compromise —— israel's prime minister. others for compromise -- israel's prime minister.— others for compromise -- israel's prime minister. everybody knows this deal has to happen. _ prime minister. everybody knows this deal has to happen. there is - prime minister. everybody knows this deal has to happen. there is no - deal has to happen. there is no alternative to it. without finding a way to resolve the issues that are at stake, this release of hostages will not happen. the at stake, this release of hostages will not happen.— at stake, this release of hostages will not happen. the families of the hosta . es will not happen. the families of the hostages taken _ will not happen. the families of the hostages taken on _ will not happen. the families of the hostages taken on october - will not happen. the families of the hostages taken on october seven . will not happen. the families of the i hostages taken on october seven have become a potent political force and a focal point for protest.— a focal point for protest. people do not like to protest _ a focal point for protest. people do not like to protest at _ a focal point for protest. people do not like to protest at times - a focal point for protest. people do not like to protest at times of - a focal point for protest. people do not like to protest at times of war. | not like to protest at times of war. the hostage families are the only ones _ the hostage families are the only ones who— the hostage families are the only ones who have legitimacy to speak out and _ ones who have legitimacy to speak out and criticise the government in a significant — out and criticise the government in a significant way. not out and criticise the government in a significant way.— a significant way. not everyone is in favour of _ a significant way. not everyone is in favour of negotiation. - a significant way. not everyone is in favour of negotiation. a - a significant way. not everyone is in favour of negotiation. a small. in favour of negotiation. a small number of israelis have been trying to stop it getting into gaza, even amidst the humanitarian crisis. i cannot understand why a country at

war is bringing humanitarian aid into... over enemy lines. this war is bringing humanitarian aid into... over enemy lines. this is a country governed _ into... over enemy lines. this is a country governed by _ into... over enemy lines. this is a country governed by a _ into... over enemy lines. this is a country governed by a fractured i country governed by a fractured coalition, a combination of mr netanyahu's party, the far right, the orthodox, and since the 7th of october, the unity party. hejoined the war cabinet along with a former general. both are seen for voices of moderation within government. the “oint to be moderation within government. tie: joint to be the responsible heads within the coalition during the war. if they leave, for netanyahu the option is either to stay with the far right coalition, in which he is even more in the hands of... article a fresh election and risk the political opinion.—

a fresh election and risk the political opinion. a fresh election and risk the olitical oinion. ., ., , political opinion. that has even led some to suggest — political opinion. that has even led some to suggest that _ political opinion. that has even led some to suggest that mr _ some to suggest that mr netanyahu, who faces corruption charges, has an incentive to prolong the war. he does not want to face the criminal charges _ does not want to face the criminal charges against him in court as an ordinary— charges against him in court as an ordinary citizen. he does not want to have _ ordinary citizen. he does not want to have to— ordinary citizen. he does not want to have to face a commission of inquiry, — to have to face a commission of inquiry, and _ to have to face a commission of inquiry, and he does not want to go down _ inquiry, and he does not want to go down in _ inquiry, and he does not want to go down in history as a field prime minister~ — down in history as a field prime minister. forallthose reasons, years— minister. forallthose reasons, years trying to cling onto power. but others — years trying to cling onto power. but others say, however unpopular he has become, within israel war still has become, within israel war still has public backing.— has become, within israel war still has public backing. netanyahu does have little incentive _ has public backing. netanyahu does have little incentive to _ has public backing. netanyahu does have little incentive to continue i have little incentive to continue the war, but they are not the incentive for israel to continue the work. it is not netanyahu's were, there is broad support for the aim of destroying hamas. in the centrist parties in this coalition support that as well.— parties in this coalition support that as well. �* ., ., , ., , that as well. ben'amin netanyahu is a famous that as well. benjamin netanyahu is a famous political _ that as well. benjamin netanyahu is a famous political survivor, - that as well. benjamin netanyahu is a famous political survivor, a - a famous political survivor, a deal—maker, but there are red lines running through any negotiations that may be even he cannot navigate.

in the end, this is not about political future of one man, but about those affected by the work. more than 100 hostages remain trapped, as do hundreds of thousands of palestinians caught in an unbearable humanitarian crisis. the birth of a baby should be the happiest of days, but in england and wales the incidences of stillbirth and infant mortality are higher than most european countries. part of that is to do with the quality of our maternal services. in 2022, the care quality commission reported that a third of services required improvement with three big issues, leadership, staffing — the royal college of midwives estmiates the nhs has a shortfall of 2,500 full time midwives — and communication. all of which were factors in the failure of care for the babies of the three sets of parents who are joining us to tonight, all of whom want an ugent national review of maternity services to make the safety of mothers and babies a priority. i'll be speaking to them all in a moment, but first here's kate.

over the last 30 years, england and wales have, broadly speaking, seen long—term reductions in the rate of both neonatal mortality and stillbirth. and that despite the fact that during this time there has also been a steady increase in the average age of mothers, meaning a higher proportion of births now involve more complex care. however, the rate of improvement falls well behind ambition. the government set a target of halving the rate of stillbirth and neonatal mortality from when the coalition government first came to power in 2010 by 2025. the latest data only goes to 2021, but you can see there were still a long way to go to hit that pledge. the ons suggests it would require a reduction of almost 900 stillbirth a year. now, international comparisons here are a bit tricky because many countries count neonatal deaths in completely different ways. but if we look at infant mortality, the rate of deaths within the first year of a child's life, of which 70—80% will be neonatal deaths, then we can see that the uk performs better than some other countries like the us and canada.

those, however, are outliers. many european countries see lower rates of infant mortality than the uk. just look at ireland or italy. japan is lower still, down here. and if we look at maternal mortality, specifically the deaths of mothers within 42 days of the end of their pregnancy, the uk also performs comparatively poorly. one study examined the maternal mortality rate of eight european countries in the mid—2010s and found that while norway had 2.7 deaths per 100,000 live births, the uk had 9.6, above france and italy and only below slovakia. the long—term study from mbrrace—uk suggests the maternal death rate in the uk has been rising and is currently the highest it has been in almost 20 years. now, in thinking why the uk does poorly here, we can remember that there will be risk factors at a population level. i have already mentioned the age of mothers, but things like obesity and smoking can also increase the risk of complications, and there are other factors, too. in the uk, the rates of stillbirth

and neonatal deaths are higher in more deprived areas and for non—white ethnic groups. and we have got to look at the quality of our maternity services. while in recent years there have been independent reviews of the performance of specific trusts in nottingham and shrewsbury, there is some suggestion poor performance is far more widespread. the care quality commission rate service provision. in 2022, more than 55% of services were rated good, a third required improvement. in 2023, positive ratings dropped and the negatives grew. now one in ten maternity services are rated inadequate, roughly a further 40% require improvement. the cqc identified three key issues — leadership, including how different midwifery and obstetric teams work together, communication, so, giving parents the information they need, and staffing. the cqc said it found examples of staffing levels well below recommended workforce numbers, with shortfalls sometimes resulting in delays in care or even one—to—one care not being available during labour.

surveys show the number of patients who say they could always find help has fallen, and the royal college of midwives estimates the nhs has a current shortfall of 2,500 full—time posts. the government has described the nhs as one of the safest places in the world to give birth, but campaigners think more could be done to tackle the problems which persist despite ambition and investigation. joining us in the studio are sian and rob channon, the parents of gethin, and lauren caulfield and aaron kilburn, whose baby daughter was called grace. fiona winser ramm and dan ramm, the parents of aliona, are also joining us from leeds. first of all, thank you very much for coming in. sian and bob, how was the pregnancy? the for coming in. sian and bob, how was the pregnancy?— the pregnancy? the pregnancy with gethin was actually _ the pregnancy? the pregnancy with gethin was actually quite _ gethin was actually quite straightforward. i hadn't had particular trouble at all. it was

only when i went into hospital and was induced that things really started to go wrong.— was induced that things really started to go wrong. what started to to wron: ? started to go wrong. what started to go wrong? were _ started to go wrong. what started to go wrong? were you _ started to go wrong. what started to go wrong? were you aware - started to go wrong. what started to go wrong? were you aware of - started to go wrong. what started to go wrong? were you aware of what i started to go wrong. what started to i go wrong? were you aware of what was happening? hat go wrong? were you aware of what was ha ttenin? ., . ., , go wrong? were you aware of what was hat-tenin? ., . ., , happening? not particularly. iwas induced in hospital, _ happening? not particularly. iwas induced in hospital, and _ happening? not particularly. iwas induced in hospital, and quite i happening? not particularly. i was| induced in hospital, and quite early on it was clear that they were not happy, they thought things were progressing to quickly. but from the point i went in, it turns out that my child's heart rate was erratic. and defeat a heart monitor was not being assessed properly? that and defeat a heart monitor was not being assessed properly?— being assessed properly? that is ritht. the being assessed properly? that is right. the fatal _ being assessed properly? that is right. the fatal heart _ being assessed properly? that is right. the fatal heart monitor- being assessed properly? that is i right. the fatal heart monitor which picks up the baby's cartwright... which is a regular thing in every single birth. —— the baby's heart rate. single birth. -- the baby's heart rate. , ., , ., rate. they were not being read properly- _ rate. they were not being read properly- and _ rate. they were not being read properly. and that _ rate. they were not being read properly. and that meant i rate. they were not being read properly. and that meant that| rate. they were not being read i properly. and that meant that action was not taken. properly. and that meant that action was not taken-— was not taken. gethin was in distress and _ was not taken. gethin was in distress and you _ was not taken. gethin was in distress and you did - was not taken. gethin was in distress and you did not i was not taken. gethin was in i distress and you did not know. so,

when gethin was born, but did the hospital, wanted the nurses, the doctor talk to about? the hospital, wanted the nurses, the doctor talk to about?— doctor talk to about? the first thing they _ doctor talk to about? the first thing they told _ doctor talk to about? the first thing they told us _ doctor talk to about? the first thing they told us was - doctor talk to about? the first thing they told us was gethin | doctor talk to about? the first i thing they told us was gethin had a very short — thing they told us was gethin had a very short life expectancy. he was not expected to last the afternoon, then the _ not expected to last the afternoon, then the day, then it gradually got longer~ _ then the day, then it gradually got longer. we were told every single day that _ longer. we were told every single day that that day was probably going to be his _ day that that day was probably going to be his last. 30, day that that day was probably going to be his last-— to be his last. so, during that time, to be his last. so, during that time. or— to be his last. so, during that time. or are _ to be his last. so, during that time, or are you _ to be his last. so, during that time, or are you having i to be his last. so, during that time, or are you having help, | time, or are you having help, counselling, where people being kind? , , , kind? yes, but when we were sent home with — kind? yes, but when we were sent home with gethin _ kind? yes, but when we were sent home with gethin after— kind? yes, but when we were sent home with gethin after a - kind? yes, but when we were sent home with gethin after a month, | kind? yes, but when we were sent i home with gethin after a month, we were basically abandoned at home with a _ were basically abandoned at home with a very— were basically abandoned at home with a very sick child on a palliative care pathway. and we were 'ust palliative care pathway. and we were just basically left to fend for ourselves with this young boy with horrific _ ourselves with this young boy with horrific medical problems. at what oint did horrific medical problems. at what point did you _ horrific medical problems. at what point did you realise... _ horrific medical problems. at what point did you realise... this - horrific medical problems. at what point did you realise... this is i horrific medical problems. at what point did you realise... this is a i point did you realise... this is a terribly traumatic time, but at what point did you realise something had really gone wrong with your medical care? ~ ., ., .,

care? well, we had an initial serious incident _ care? well, we had an initial serious incident review- care? well, we had an initial| serious incident review which care? well, we had an initial- serious incident review which said nothing had gone wrong, and then sometime later, because of the involvement of an expert reviewing our care, we became aware quite quickly then with his report saying that it was substandard. mas quickly then with his report saying that it was substandard. was anyone advocatin: that it was substandard. was anyone advocating for _ that it was substandard. was anyone advocating for you? _ that it was substandard. was anyone advocating for you? did _ that it was substandard. was anyone advocating for you? did you - that it was substandard. was anyone advocating for you? did you get i that it was substandard. was anyone advocating for you? did you get a i advocating for you? did you get a sense from the hospital that anyone was looking out for you and taking care of your case? i was looking out for you and taking care of your case?— care of your case? i think it was the exact _ care of your case? i think it was the exact opposite. _ care of your case? i think it was the exact opposite. it _ care of your case? i think it was the exact opposite. it felt i care of your case? i think it was the exact opposite. it felt like l the exact opposite. it felt like from — the exact opposite. it felt like from when we receive the first incident — from when we receive the first incident review, when we met the lead obstetrician, they were working against _ lead obstetrician, they were working against us _ lead obstetrician, they were working against us. it was the exact opposite _ against us. it was the exact opposite of working with us and trying _ opposite of working with us and trying to— opposite of working with us and trying to help us understand what happened that day. tell trying to help us understand what happened that day.— trying to help us understand what happened that day. tell me about ttettin the happened that day. tell me about getting the care — happened that day. tell me about getting the care pack _ happened that day. tell me about getting the care pack for - happened that day. tell me about getting the care pack for gethin. l happened that day. tell me about i getting the care pack for gethin. as you say, yes multiple and complex needs. . , you say, yes multiple and complex needs. ., , ., .., you say, yes multiple and complex needs. .,, ., . needs. there was no care package when we left _ needs. there was no care package when we left hospital. _ needs. there was no care package when we left hospital. we - needs. there was no care package when we left hospital. we did i needs. there was no care package when we left hospital. we did not| when we left hospital. we did not have a single night of care assistants until he was a year old.

this was a child that could quite easily injure himself at night. tube fed and with an inadequate swallow, so you could have suffocated. swansea bay university health board spokesperson says, our hearts go out to the family, we fully recognise the challenges they faced. we acknowledge there was a delay in providing the ongoing care package for gethin. we are extremely sorry for gethin. we are extremely sorry for that. when you hear that, when you read that, what does it make you think? , ., , ., think? pretty angry. i mean, we have had to make — think? pretty angry. i mean, we have had to make serious _ think? pretty angry. i mean, we have had to make serious incident - had to make serious incident reviews. _ had to make serious incident reviews, neither have been of a standard — reviews, neither have been of a standard that the expert in our case expected _ standard that the expert in our case expected them to be. neither provided _ expected them to be. neither provided answers as to what happened to gethin _ provided answers as to what happened to gethin that day. nothing is answered by we were abandoned for the first— answered by we were abandoned for the first year of his life in quite horrific— the first year of his life in quite horrific circumstances for his physical— horrific circumstances for his physical health, but also for our

mental— physical health, but also for our mental health. it deteriorated to a point _ mental health. it deteriorated to a point where it should never have been _ point where it should never have been. some of the thoughts that we were thinking and some of the things were thinking and some of the things we did _ were thinking and some of the things we did wear, you know, too painful to talk— we did wear, you know, too painful to talk about.— to talk about. let me talk now to lauren to talk about. let me talk now to lauren and _ to talk about. let me talk now to lauren and aaron. _ to talk about. let me talk now to lauren and aaron. your - to talk about. let me talk now to lauren and aaron. your daughter grace was born after again a regular pregnancy until the last few days. there were problems the last few days. there were problems the last few da s. ., ., , there were problems the last few das. ., .,_ ., _ days. through the early pregnancy, eve hint days. through the early pregnancy, everything was _ days. through the early pregnancy, everything was fine. _ days. through the early pregnancy, everything was fine. it _ days. through the early pregnancy, everything was fine. it was - days. through the early pregnancy, everything was fine. it was round . everything was fine. it was round about the first couple of weeks, 31t week appointment when they did the cheque, she was showing as 32 centimetres. they did it again instantly with the measurement. then that time showed 31t centimetres. then at the 36 week appointment, she showed on the growth as 35 centimetres. but none of these were being plotted on the growth chart, so her growth was clearly falling off of the expected. haifa so her growth was clearly falling off of the expected.— so her growth was clearly falling off of the expected. how was this

communicated _ off of the expected. how was this communicated to _ off of the expected. how was this communicated to you? _ off of the expected. how was this communicated to you? it - off of the expected. how was this communicated to you? it wasn't. | off of the expected. how was this i communicated to you? it wasn't. when we went to the — communicated to you? it wasn't. when we went to the appointments, - communicated to you? it wasn't. when we went to the appointments, they i we went to the appointments, they were not shows the growth chart, we were not shows the growth chart, we were not shows the growth chart, we were not seeing where she was plotting. it was not actually plotted ever.— plotting. it was not actually lotted ever. ., , ., , , plotted ever. aaron, yet no sense an hint plotted ever. aaron, yet no sense anything was _ plotted ever. aaron, yet no sense anything was wrong? _ plotted ever. aaron, yet no sense anything was wrong? there i plotted ever. aaron, yet no sense anything was wrong? there was i plotted ever. aaron, yet no sense | anything was wrong? there was no sense anything was going wrong? we had no idea at all. there were a couple — had no idea at all. there were a couple of— had no idea at all. there were a couple of times that lauren felt she had reduced movements, and we went to the _ had reduced movements, and we went to the hospital, we were told not to worry, _ to the hospital, we were told not to worry, everything was fine. so we had no _ worry, everything was fine. so we had no reason whatsoever to suspect there _ had no reason whatsoever to suspect there was _ had no reason whatsoever to suspect there was something amiss. but there was something — there was something amiss. but there was something very _ there was something amiss. but there was something very amiss, _ there was something amiss. but there was something very amiss, very i was something very amiss, very sadly. i think her death was from sudden lack of oxygen, was that right? sudden lack of oxygen, was that ri . ht? , ., , ., sudden lack of oxygen, was that riuht? ., , ., right? the postmortem showed acute h oxia. right? the postmortem showed acute hypoxia- what — right? the postmortem showed acute hypoxia. what was _ right? the postmortem showed acute hypoxia. what was the _ right? the postmortem showed acute hypoxia. what was the hospital - hypoxia. what was the hospital resonse hypoxia. what was the hospital response when _ hypoxia. what was the hospital response when you _ hypoxia. what was the hospital response when you went - hypoxia. what was the hospital l response when you went through hypoxia. what was the hospital - response when you went through this terrible trauma?— terrible trauma? there was not really any _ terrible trauma? there was not really any response. _ terrible trauma? there was not really any response. once - terrible trauma? there was not really any response. once we l terrible trauma? there was not i really any response. once we had left the hospital after losing grace, we did not hearfrom anyone for 15 days. we were completely left by ourselves, we had no idea what to

do, we were lost and had no support from anyone. do, we were lost and had no support from anyone-— do, we were lost and had no support from an one. ~ ., ,, ., a, ., from anyone. what did you do, aaron? it is exactly — from anyone. what did you do, aaron? it is exactly as — from anyone. what did you do, aaron? it is exactly as lauren _ from anyone. what did you do, aaron? it is exactly as lauren was _ from anyone. what did you do, aaron? it is exactly as lauren was saying, - it is exactly as lauren was saying, we felt _ it is exactly as lauren was saying, we felt completely lost. we did have a bereavement midwife come out eventually, who had explained there was a _ eventually, who had explained there was a lack_ eventually, who had explained there was a lack of key medication between the hospital and the midwife between two different trusts. —— lack of clear_ two different trusts. —— lack of clear communication. it seems very surreal_ clear communication. it seems very surreal now — clear communication. it seems very surreal now— clear communication. it seems very surreal now. you comforted yourself b auoin surreal now. you comforted yourself by going to — surreal now. you comforted yourself by going to the _ surreal now. you comforted yourself by going to the funeral? _ surreal now. you comforted yourself by going to the funeral? that - surreal now. you comforted yourself by going to the funeral? that is - by going to the funeral? that is ri . ht. by going to the funeral? that is right- grace _ by going to the funeral? that is right. grace was _ by going to the funeral? that is right. grace was in _ by going to the funeral? that is right. grace was in the - by going to the funeral? that is right. grace was in the funerall by going to the funeral? that is - right. grace was in the funeral home for a couple — right. grace was in the funeral home for a couple of weeks, and i went everyday — fora couple of weeks, and i went everyday i— for a couple of weeks, and i went everyday. ijust sat with her. i just _ everyday. ijust sat with her. i just wanted to spend as much time as i could _ just wanted to spend as much time as i could with _ just wanted to spend as much time as i could with my daughter while i had the opportunity. the i could with my daughter while i had the opportunity-— the opportunity. the spokesman for bradford teaching _ the opportunity. the spokesman for bradford teaching hospital - the opportunity. the spokesman for bradford teaching hospital said, - the opportunity. the spokesman for bradford teaching hospital said, we| bradford teaching hospital said, we would like to express our sincere condolences to grace's family for their sad loss. but they then went on to talk about, we have completed

action is appropriate trust, committed to learning from this incident. the problem of learning from this incident will help other people, but it does not help you. that people, but it does not help you. git the end of the day, they failed to do very basic rules of a midwife, not measuring properly, not escalating when i am saying she is moving around less. very basic midwifery roles are not being done. i'm going to come back and talk to you specifically about something that happened after race's death. just turning to fiona and dan, aliona, your daughter, died very soon after birth. the inquest said it was a gross failure of the most basic nature. when you are in the early stages of labour, i understand that the hospital advised you to stay at home? what happened? i had been booked in for induction in the _

i had been booked in for induction in the early— i had been booked in for induction in the early hours _ i had been booked in for induction in the early hours before - i had been booked in for induction in the early hours before that, - i had been booked in for induction in the early hours before that, i. in the early hours before that, i spontaneously _ in the early hours before that, i spontaneously went _ in the early hours before that, i spontaneously went into - in the early hours before that, i| spontaneously went into labour. in the early hours before that, i- spontaneously went into labour. we had numerous — spontaneously went into labour. we had numerous conversations - spontaneously went into labour. we had numerous conversations with i had numerous conversations with midwifes— had numerous conversations with midwifes on— had numerous conversations with midwifes on the _ had numerous conversations with midwifes on the fun _ had numerous conversations with midwifes on the fun and - had numerous conversations with midwifes on the fun and at - had numerous conversations with midwifes on the fun and at no - had numerous conversations with . midwifes on the fun and at no point where _ midwifes on the fun and at no point where we _ midwifes on the fun and at no point where we asked _ midwifes on the fun and at no point where we asked for— midwifes on the fun and at no point where we asked for any— midwifes on the fun and at no point where we asked for any form - midwifes on the fun and at no point where we asked for any form of- midwifes on the fun and at no point where we asked for any form of any physical— where we asked for any form of any physical assessment _ where we asked for any form of any physical assessment even - where we asked for any form of any physical assessment even when - where we asked for any form of any physical assessment even when we | physical assessment even when we raised _ physical assessment even when we raised concerns— physical assessment even when we raised concerns around _ physical assessment even when we raised concerns around movementl physical assessment even when we . raised concerns around movement and discharge, _ raised concerns around movement and discharge, everything _ raised concerns around movement and discharge, everything was _ raised concerns around movement and discharge, everything was dismissed. i discharge, everything was dismissed. we were _ discharge, everything was dismissed. we were told — discharge, everything was dismissed. we were told to — discharge, everything was dismissed. we were told to stay _ discharge, everything was dismissed. we were told to stay at _ discharge, everything was dismissed. we were told to stay at home. - discharge, everything was dismissed. we were told to stay at home. it - discharge, everything was dismissed. we were told to stay at home. it was| we were told to stay at home. it was a very— we were told to stay at home. it was a very long _ we were told to stay at home. it was a very long time _ we were told to stay at home. it was a very long time before _ we were told to stay at home. it was a very long time before we _ we were told to stay at home. it was a very long time before we actually. a very long time before we actually were told _ a very long time before we actually were told to — a very long time before we actually were told to come _ a very long time before we actually were told to come into _ a very long time before we actually were told to come into hospital. i a very long time before we actually were told to come into hospital. [i were told to come into hospital. i think were told to come into hospital. think you had problems with the cardio tachograph as well, the monitoring of aliona.- cardio tachograph as well, the monitoring of aliona. when we got to hos - ital her monitoring of aliona. when we got to hospital her heart _ monitoring of aliona. when we got to hospital her heart rate _ monitoring of aliona. when we got to hospital her heart rate rose _ hospital her heart rate rose significantly over the course of the day to _ significantly over the course of the day to the — significantly over the course of the day to the point where she was classified — day to the point where she was classified as pathological around 11 at night _ classified as pathological around 11 at night but the problem was twofold, _ at night but the problem was twofold, firstly we weren't being told about these categorisations so the midwives were falsifying records

and they— the midwives were falsifying records and they couldn't read the cardio tachograph correctly, at the inquest midwifes— tachograph correctly, at the inquest midwifes limerick were shown things they didn't _ midwifes limerick were shown things they didn't agree with, the previous categorisations and what that meant was aliona _ categorisations and what that meant was aliona was pathological for 5.5 hours _ was aliona was pathological for 5.5 hours before she was delivered and subsequently died.— subsequently died. leeds teaching hos - itals subsequently died. leeds teaching hospitals say _ subsequently died. leeds teaching hospitals say as — subsequently died. leeds teaching hospitals say as a _ subsequently died. leeds teaching hospitals say as a result _ subsequently died. leeds teaching hospitals say as a result of - subsequently died. leeds teaching hospitals say as a result of the - hospitals say as a result of the findings of the inquest seven recommendations have been put in place. i want to ask you because i know you have told our producer what was told to you by a postmortem nurse, what did she say to you? t nurse, what did she say to you? i was told sometimes babiesjust died. that made _ was told sometimes babiesjust died. that made absolutely— was told sometimes babiesjust died. that made absolutely no _ was told sometimes babiesjust died. that made absolutely no sense - was told sometimes babiesjust died. that made absolutely no sense to - was told sometimes babiesjust died. i that made absolutely no sense to me, you don't _ that made absolutely no sense to me, you don't go— that made absolutely no sense to me, you don't go from _ that made absolutely no sense to me, you don't go from being _ that made absolutely no sense to me, you don't go from being a _ that made absolutely no sense to me, you don't go from being a live, - you don't go from being a live, healthy— you don't go from being a live, healthy being _ you don't go from being a live, healthy being who _ you don't go from being a live, healthy being who was - you don't go from being a live, healthy being who was alive i you don't go from being a live, i healthy being who was alive one minute — healthy being who was alive one minute and _ healthy being who was alive one minute and dead _ healthy being who was alive one minute and dead the _ healthy being who was alive one minute and dead the next. - healthy being who was alive one minute and dead the next. the. minute and dead the next. the narrative — minute and dead the next. the narrative we _ minute and dead the next. the narrative we were _ minute and dead the next. the narrative we were given - minute and dead the next. the narrative we were given by - minute and dead the next. the narrative we were given by the |

narrative we were given by the hospital— narrative we were given by the hospital contributed _ narrative we were given by the hospital contributed to - narrative we were given by the hospital contributed to that. l narrative we were given by the i hospital contributed to that. we were _ hospital contributed to that. we were told — hospital contributed to that. we were told over _ hospital contributed to that. we were told over 48 _ hospital contributed to that. we were told over 48 hours - hospital contributed to that. we were told over 48 hours after i hospital contributed to that. we. were told over 48 hours after she died that— were told over 48 hours after she died that they _ were told over 48 hours after she died that they had _ were told over 48 hours after she died that they had no _ were told over 48 hours after she died that they had no idea - were told over 48 hours after she died that they had no idea why i were told over 48 hours after she. died that they had no idea why she was dead _ died that they had no idea why she was dead and _ died that they had no idea why she was dead and we _ died that they had no idea why she was dead and we believe _ died that they had no idea why she was dead and we believe them, i died that they had no idea why she| was dead and we believe them, we still trusted — was dead and we believe them, we still trusted everything _ was dead and we believe them, we still trusted everything they- was dead and we believe them, we still trusted everything they were l still trusted everything they were saying _ still trusted everything they were saying through— still trusted everything they were saying. through the _ still trusted everything they were saying. through the investigation processes— saying. through the investigation processes and _ saying. through the investigation processes and inquests _ saying. through the investigation processes and inquests it - saying. through the investigation processes and inquests it has- saying. through the investigation . processes and inquests it has come to light _ processes and inquests it has come to light that — processes and inquests it has come to light that within _ processes and inquests it has come to light that within 48 _ processes and inquests it has come to light that within 48 hours - processes and inquests it has come to light that within 48 hours after l to light that within 48 hours after she had _ to light that within 48 hours after she had died. _ to light that within 48 hours after she had died, they— to light that within 48 hours after she had died, they knew- to light that within 48 hours after she had died, they knew that - to light that within 48 hours after she had died, they knew that her| to light that within 48 hours after - she had died, they knew that her ccg had not _ she had died, they knew that her ccg had not been — she had died, they knew that her ccg had not been managed _ she had died, they knew that her ccg had not been managed properly, - she had died, they knew that her ccgj had not been managed properly, that it should _ had not been managed properly, that it should have — had not been managed properly, that it should have been— had not been managed properly, that it should have been escalated - had not been managed properly, that it should have been escalated and - it should have been escalated and she should — it should have been escalated and she should have _ it should have been escalated and she should have been— it should have been escalated and she should have been delivered . it should have been escalated and - she should have been delivered hours before _ she should have been delivered hours before yet— she should have been delivered hours before yet all— she should have been delivered hours before yet all the _ she should have been delivered hours before yet all the information - before yet all the information continue _ before yet all the information continue to— before yet all the information continue to be _ before yet all the information continue to be withheld, - before yet all the information continue to be withheld, so. before yet all the information. continue to be withheld, so we before yet all the information - continue to be withheld, so we left the hospital. — continue to be withheld, so we left the hospital, came _ continue to be withheld, so we left the hospital, came home - continue to be withheld, so we left the hospital, came home and - the hospital, came home and effectively _ the hospital, came home and effectively blamed _ the hospital, came home and effectively blamed ourselvesl the hospital, came home and - effectively blamed ourselves because the only— effectively blamed ourselves because the only information _ effectively blamed ourselves because the only information we _ effectively blamed ourselves because the only information we had - effectively blamed ourselves because the only information we had was - effectively blamed ourselves because the only information we had was the i the only information we had was the concerns— the only information we had was the concerns we — the only information we had was the concerns we had _ the only information we had was the concerns we had during _ the only information we had was the concerns we had during labour- the only information we had was the concerns we had during labour thatl concerns we had during labour that we tried _ concerns we had during labour that we tried to — concerns we had during labour that we tried to raise _ concerns we had during labour that we tried to raise that _ concerns we had during labour that we tried to raise that had _ concerns we had during labour that we tried to raise that had been - we tried to raise that had been dismissed _ we tried to raise that had been dismissed. we _ we tried to raise that had been dismissed. we blamed - we tried to raise that had been . dismissed. we blamed ourselves thinking — dismissed. we blamed ourselves thinking we — dismissed. we blamed ourselves thinking we should _ dismissed. we blamed ourselves thinking we should have - dismissed. we blamed ourselves thinking we should have trusted i dismissed. we blamed ourselves. thinking we should have trusted our -ut thinking we should have trusted our gut instinct — thinking we should have trusted our aut instinct. ~ ., , thinking we should have trusted our gut instinct-— gut instinct. what is in all your stories and _ gut instinct. what is in all your stories and there _ gut instinct. what is in all your stories and there is _ gut instinct. what is in all your stories and there is no - gut instinct. what is in all your stories and there is no one - stories and there is no one advocating for you and you felt on your own. lauren, after grace's death you worked in an office and

were in administration but you took a complete change in your life. t a complete change in your life. i decided to go into midwifery a complete change in your life. t decided to go into midwifery after losing grace, i did an access course and just this past september started at the university of manchester. does that easier, ? t at the university of manchester. does that easier, ?_ at the university of manchester. does that easier, ? does that easier,? i wouldn't say he's as the _ does that easier,? i wouldn't say he's as the trauma _ does that easier,? i wouldn't say he's as the trauma but _ does that easier,? i wouldn't say he's as the trauma but -- - does that easier,? i wouldn't say he's as the trauma but -- he'ss l does that easier,? i wouldn't say i he's as the trauma but -- he'ss the he's as the trauma but —— he'ss the trauma but i feel like she is living through me. it is her legacy. malt? through me. it is her legacy. now that ou through me. it is her legacy. now that you are _ through me. it is her legacy. now that you are learning _ through me. it is her legacy. now that you are learning about midwifery are you seeing things that should have been done practically every day that you were there, you see something? mil every day that you were there, you see something?— see something? all the time. the bi est see something? all the time. the biggest thing _ see something? all the time. the biggest thing we _ see something? all the time. the biggest thing we are _ see something? all the time. the biggest thing we are taught - see something? all the time. the biggest thing we are taught is - see something? all the time. the biggest thing we are taught is to i see something? all the time. the i biggest thing we are taught is to be an advocate for women. the number one thing is always be there for women and birthing people and support them and all three of our cases that wasn't done. what you didn't feel a midwife was advocating for you? not at any point. what

for you? not at any point. what about you? _ for you? not at any point. what about you? i — for you? not at any point. what about you? ithink— for you? not at any point. what about you? i think in _ for you? not at any point. what about you? i think in some - for you? not at any point. what - about you? i think in some instances perhaps they — about you? i think in some instances perhaps they were — about you? i think in some instances perhaps they were but _ about you? i think in some instances perhaps they were but the _ about you? i think in some instances perhaps they were but the doctors i perhaps they were but the doctors leading _ perhaps they were but the doctors leading the case weren't actually acting _ leading the case weren't actually acting on— leading the case weren't actually acting on what they were being told. it is clear— acting on what they were being told. it is clear that things were written in our— it is clear that things were written in our notes and subsequently there is a suggestion they have been changed — is a suggestion they have been changed. it doesn't feel that as a group _ changed. it doesn't feel that as a group they were advocating for us. fiona, _ group they were advocating for us. fiona, there have been a number of different issues in different trusts but you want a complete review of maternity services and the way that they are delivered for people, what do you want to see changed? there needs to be — do you want to see changed? there needs to be so _ do you want to see changed? there needs to be so much _ do you want to see changed? there needs to be so much changed. - do you want to see changed? il—urr needs to be so much changed. there needs to be so much changed. there needs to be changed on the trust wide level, but there also needs to be change from governing bodies, regulatory bodies such as gmc, the

coc. hate regulatory bodies such as gmc, the cqc. ~ . regulatory bodies such as gmc, the coc. ~ ., ., _ , regulatory bodies such as gmc, the coc. ., ., ., cqc. we need a whole system analysis in this country — cqc. we need a whole system analysis in this country of— cqc. we need a whole system analysis in this country of everything, _ cqc. we need a whole system analysis in this country of everything, but - in this country of everything, but we have — in this country of everything, but we have had poor experiences with governing — we have had poor experiences with governing bodies like the coc, he would _ governing bodies like the coc, he would have thought talking about people _ would have thought talking about people advocating for you would be someone _ people advocating for you would be someone who could support you after your baby _ someone who could support you after your baby dies in trying to get the film your baby dies in trying to get the right result in terms of addressing the failings that the service providers have made, yet still pause to ask— providers have made, yet still pause to ask to— providers have made, yet still pause to ask to go— providers have made, yet still pause to ask to go back to cqc and put our case forward — to ask to go back to cqc and put our case forward about why we believe or know for— case forward about why we believe or know for example our baby has been failed _ know for example our baby has been failed and _ know for example our baby has been failed and why there have been breaches— failed and why there have been breaches of the health care act but these _ breaches of the health care act but these governing bodies aren't doing anything _ these governing bodies aren't doing anything and they are not fit for purpose — anything and they are not fit for purpose. the reality is we need an inguiry— purpose. the reality is we need an inquiry into— purpose. the reality is we need an inquiry into this before the government are forced to do this. thank— government are forced to do this. thank you — government are forced to do this. thank you all very much for coming tonight. i'm joined now by christine mccourt, professor of maternal and child health at city university london.

what do you make of what you have heard from all these different parents? t heard from all these different arents? ~' ., ., heard from all these different arents? ~ ., ., parents? i think one of the sad thins is parents? i think one of the sad things is we — parents? i think one of the sad things is we have _ parents? i think one of the sad things is we have heard - parents? i think one of the sad things is we have heard about| parents? i think one of the sad | things is we have heard about a parents? i think one of the sad - things is we have heard about a lot of these problems before. there have been a number of maternity inquiry reports and i have been doing research for quite a long time and unfortunately we have seen that pattern. unfortunately we have seen that attern. ~ ., , , pattern. with all these reports it is different _ pattern. with all these reports it is different and _ pattern. with all these reports it is different and yet _ pattern. with all these reports it is different and yet to _ pattern. with all these reports it is different and yet to listen - pattern. with all these reports it is different and yet to listen to i pattern. with all these reports it| is different and yet to listen to an overarching improvement. we have a massive shortage of midwives. hate massive shortage of midwives. we have a massive shortage of midwives. , have a massive shortage of staff and i think it it is absolutely fundamental because the services are as you have described, people have more medical needs now. there are more medical needs now. there are more complications but also as the rate of interventions we have heard about, cesarean sections has increased quite dramatically in this country, there is a lot of work associated with these kind of procedures.

associated with these kind of procedures-— associated with these kind of rocedures. ., ., procedures. there are also fewer staff available. _ procedures. there are also fewer staff available. a _ procedures. there are also fewer staff available. a simple - procedures. there are also fewer i staff available. a simple tachograph goes over the tummy and in these cases we heard tonight at least two of these cases, they were not monitored properly. we of these cases, they were not monitored properly.— of these cases, they were not monitored properly. we have really aood monitored properly. we have really good policies. _ monitored properly. we have really good policies, excellent _ monitored properly. we have really good policies, excellent technically| good policies, excellent technically evidence—based guidelines in this country but the implementation of these policies hasn't been so solid. a key thing is continuity of care. these breakdowns in communication and in passing information on, stop not having the time to understand the possible risks. it not having the time to understand the possible risks.— the possible risks. it must be incredibly _ the possible risks. it must be incredibly stressful _ the possible risks. it must be incredibly stressful for - the possible risks. it must be i incredibly stressful for midwives when there is such a shortage but the key thing is the cqc were talking about, leadership, laughing and communication. these are all fundamental to good care. —— staffing. you heard fiona say that nurses said some babies just died.

even the idea of the manner of