to services and for future feelings to be identified far more quickly? underpinning issues in maternity care is a case across so much of our nhs is the workforce. only ten months ago as a first—time mother, i experience just months ago as a first—time mother, i experiencejust how months ago as a first—time mother, i experience just how stretched to the limit the maternity services are. the nhs now losing more midwives, faster than it can recruit them. i recently pc survey showed that almost one quarter of women were unable to get help when they need it during labour. hundreds of pregnant women were turned away from maternity wards cheer because there were not beds available —— staff available to care for them. can the secretary of state tell the house what he believes to ensure the nhs recruits the midwives it needs and

what he's doing to keep the midwives we have in post. it is only with the necessary workforce that the nhs will be able to women receive the care that they need and prioritises their safety. the security and respect is all that families who suffered so much at shrewsbury won't and all the women who put their their babies lives in the hands of nhs want. thank you. secretary of state.— secretary of state. thank you. i thank the _ secretary of state. thank you. i thank the honourable _ secretary of state. thank you. i thank the honourable lady - secretary of state. thank you. i thank the honourable lady for i secretary of state. thank you. i i thank the honourable lady for her remarks at it is not often we get to see in this chamber but i agree without wholeheartedly with what she just shared, she is a right to talk about this is a fight forjustice and how these brave families have

been so persistent and coming forward with what had been done to them and what had gone wrong, this inquiry may never have happened and she is right to say that but also to talk about institutional failure, mistrust and the first report set that out in detail and we are seeing that out in detail and we are seeing that in much more detail. she talks rightly about patient safety and she will know the government has always set out plans to appoint a patient safety commissioner and that will be made soon but we need to do more and thatis made soon but we need to do more and that is why with the interim report it was absolutely right to accept all the recommendations including the immediate and absent actions needed, in that report there were seven of those and 27 local actions and i also can tell her at the house

always actions from the interim report then backed by the £95 million of funding and also the recommendations in this final report and many more quite rightly that they have all been accepted and backed by at least £127 million of funding, much of that going to workforce. when it comes to workforce. when it comes to workforce it is also worth saying because she is right about the need to increase the size of the workforce especially in terms of midwives that when it comes to acceptance for student nurses and midwives last years of the highest country had seen and decades but clearly there is much more to do. today's report goes beyond my darkest fears when i commissioned it as health secretary in 2016, i was approached by a 23 families and we hear today over 200 babies might be alive today if better care had been provided. i want to thank donna ockenden and her team for an

incredible investigation and i want to thank the health secretary for his compassionate and comprehensive response to the house today. donna ockenden doesn't usually want recommendation, she talks about immediately essential actions so can i ask him what is his deadline by when all those actions will be implemented because that is something every expected mother and the country desperately wants to know. can i gently say to him that whilst i warmly welcome more midwives and doctors at is not consistent to do that and vote down the moment from the house of lords today on the health though which would make sure we never had those shortages again. can i also finally pay tribute to the people who came to talk to me about the daughter kate who died and in 2016 when i was

health secretary and because of the blame culture and culture of fear and the nhs it was left to them and many otherfamilies to and the nhs it was left to them and many other families to fight for justice. can this be the last time we put that burden on the shoulders of the believed families and build a culture and the nhs which is open, transparent and except that things go wrong but hungry to learn from mistakes so we never again repeat tragedies. i mistakes so we never again repeat tracedies. . , . ., tragedies. i agree very much and also want to _ tragedies. i agree very much and also want to acknowledge - tragedies. i agree very much and - also want to acknowledge ultimately this report took place because of his decision to ask donna ockenden to do the review but he is connect that he in turn did that because of the bravery of the families that had come to see him, especially davies and griffiths families and he is

right to say that. in his question about the immediate essential actions with the interim report there were seven such actions, the trust has implemented all of those across the nhs, they are either fully or partially implemented. with this report they are also such actions recommended and the implementation of that has already begun. we havejust received implementation of that has already begun. we have just received the report but i have asked for a timetable by when that will all be done and i want to see that done as quickly as possible and then also his point about workforce is very important and i hope you welcomes for the first time the nhs has been asked to set out a 15 year workforce plan. i asked to set out a 15 year workforce lan. . asked to set out a 15 year workforce . ian, ., ., asked to set out a 15 year workforce ian, ., ., ., , asked to set out a 15 year workforce plan. i want to 'oin my colleagues by thanking — plan. i want to 'oin my colleagues by thanking au— plan. i want to join my colleagues by thanking all the _ plan. i want to join my colleagues by thanking all the families - plan. i want to join my colleagues by thanking all the families who l by thanking all the families who have bravely come forward to share their experiences, in particular

those whose persistence have led to this review and i hope women and babies across shropshire and the uk will be safer and the future as a result. i would like to thank donna ockenden and her team for their thoroughness in reviewing the tragic cases. i am sure the secretary of state for likely this can never be allowed to happen again at the deaths of these babies must not be in vain. this must be a turning point for maternity services and england. donna ockenden has endorsed the findings of the select committee and recommended an immediate investment of up to £300 million per year is required to keep women safe so i welcome these guarantees that the immediate and essential actions will be implemented but i would like to ask whether he will commit the additional resources recommended. thank you for comments and i can

assure how her constituents will be safer as a result of those brave families coming forward and this report and indeed families across england. when it comes to resources she will have heard me talk about the 95 million given at the time of the 95 million given at the time of the entered and report plus 127 million in the last few days for maternity services and we will keep that under review. i maternity services and we will keep that under review.— that under review. i would also like to thank the _ that under review. i would also like to thank the secretary _ that under review. i would also like to thank the secretary of _ that under review. i would also like to thank the secretary of state - that under review. i would also like to thank the secretary of state forl to thank the secretary of state for his very welcome statement today. i would also like to thank the ministerfor her work in would also like to thank the minister for her work in this area. i want to pay tribute to the member for southwest study for everything he has done for patient safety, he has led the way and i am grateful for this. has led the way and i am grateful forthis. does has led the way and i am grateful for this. does he believe that what we have seen at shrewsbury and telford hospital trust was indicative of a culture where senior

management where unaccountable, where no one felt responsible, where fillings were minimised, poor care was normalised and women's voices were not hurt and will he do everything he can to increase accountability of senior management across the nhs so that institutional blindness as we have seen here can never again cause such harm to those to put their trust in the nhs. i thank out for her approach and role in helping to make this report happen and how she has what with ministers and my department on this most important of issues. she is right to talk about the importance of culture, especially when it is absolutely clear that the voices of women we have not heard, time and i want to reassure her we will implement all the recommendations in this report but even broader when it comes to women's voices that will be at the heart of the upcoming health

strategy. at the heart of the upcoming health strate: . ., , . at the heart of the upcoming health strate. . ., , . . at the heart of the upcoming health strate . ., , ., ., strategy. today is an important day for maternity _ strategy. today is an important day for maternity safety _ strategy. today is an important day for maternity safety and _ strategy. today is an important day for maternity safety and be - strategy. today is an important day| for maternity safety and be tribbett to the families directly affected, many of whom have given evidence to the ockenden review. i want to put a father who lost his baby during the morecambe scandal and he said one of the most harmful experiences were seeing influential people in the maternity world diminish the findings of the investigation. i joined him and saying we must not allow that to happen with this report and they urge the secretary of states to ensure instead that the believed families should be allowed a process of truth, reconciliation and healing instead of any denial of the truth of what happened. i agree and she is right _ the truth of what happened. i agree and she is right to _ the truth of what happened. i agree and she is right to raise _ the truth of what happened. i agree and she is right to raise the - and she is right to raise the importance of the morecambe bay investigation will the report was completed in 2015 and therefore to four recommendations. —— there were

44 recommendations, 18 have been implemented and 26 from the wider nhs. i implemented and 26 from the wider nhs. ., 4' implemented and 26 from the wider nhs. ., ~ ., ., ~ ., nhs. i would like to thank him for both the tone _ nhs. i would like to thank him for both the tone and _ nhs. i would like to thank him for both the tone and substance - nhs. i would like to thank him for both the tone and substance of i both the tone and substance of his response to this devastating report and to add my voice to the consensus across the house of the way this is being handled is utterly vital and we must make sure the nhs does take on board donna ockenden's recommendations. she and her team are being thanked for the work they have done, they have painstakingly reviewed these cases going back 20 years and it must have been harrowing for them as it has been for all the families so tragically affected. i would like to praise the courage and tenacity of the davies

family who were my constituents when they lost their baby kate in awful circumstances. it was they who kept pressing for answers from shrewsbury and telford hospital trust and which led me to take them to see the health secretary who agreed to watch this review five years ago for they are no longer my constituents and i understand they are now keen to focus their attention on their family having been leben with this trauma since 2009. —— living with this trauma. does he recognise the ockenden review has raised fundamental questions for maternity services across the nhs over the culture of so—called normal birth and how a focus on targets and successive governments rather than patient outcomes can distort clinical best practice and tragically patient safety and from

his discussion with the current chief executive se satisfied that the current management and clinical teams have accepted the local actions for learning made by the initial report and are committed to a study and implement rapidly all further recommendations specific to this trust. finally what reassurance can he give to the thousands of expectant mothers and shropshire and telford that the maternity services there are safe and that patient safety is paramount. i there are safe and that patient safety is paramount.— there are safe and that patient safety is paramount. i thank him for the way he — safety is paramount. i thank him for the way he has _ safety is paramount. i thank him for the way he has also _ safety is paramount. i thank him for the way he has also what _ safety is paramount. i thank him for the way he has also what with - safety is paramount. i thank him for the way he has also what with my i the way he has also what with my department and my predecessor representing his constituency throughout this investigation. he has talked about the so—called normal birth and he has right to use the so—called because the only normal birth as a safe berth and thatis normal birth as a safe berth and that is what the nhs should be working to add that clearly did not

happen unless trust and this report has made it absolutely clearjust as importantly a number of recommendations including for the local nhs trust and i can absolutely reassure him including from my conversation today with the chief executive that the recommendations from the entered and report have all been implemented by his local trust and the ones in this report have all been accepted. flan and the ones in this report have all been accepted.— and the ones in this report have all been accepted. can i start by paying tribute to the _ been accepted. can i start by paying tribute to the families _ been accepted. can i start by paying tribute to the families affected - been accepted. can i start by paying tribute to the families affected and l tribute to the families affected and also thank donna ockenden and her team for the recommendations. more midwives are leaving the profession than adjoining it so it cannot run equally safe services across nhs trusts without the appropriate staffing levels. i hope the secretary of state will be able to outline and further detail what the government is doing to ensure we have safe staffing levels across all

nhs trusts in order to provide care for pregnant women. she nhs trusts in order to provide care for pregnant women.— nhs trusts in order to provide care for pregnant women. she is right to talk about the _ for pregnant women. she is right to talk about the importance - for pregnant women. she is right to talk about the importance of - for pregnant women. she is right to talk about the importance of having j talk about the importance of having the right workforce, certainly more midwives. i can tell her last year there were 30,000 acceptances for nursing and midwifery courses, the highest and a decade and also in terms of recruitment supported by the extra funding the government has put in place grants for students to take on courses and also when appropriate focus on international recruitment. this courageous report today is clear, the key infection rates contributed to peacetime. i'm pleased following a recommendation from the committee nhs are no longer being assessed on performance for the cesarean rates. will the secretary of state ensure where

cesarean rates remain artificially low interest so this dangerous normal birth ideology is eradicated from the nhs once and for all? mr from the nhs once and for all? m speaker, from the nhs once and for all? ii speaker, the from the nhs once and for all? m speaker, the answer from the nhs once and for all? ii speaker, the answer is yes. from the nhs once and for all? mr| speaker, the answer is yes. again, from the nhs once and for all? mr i speaker, the answer is yes. again, i would also — speaker, the answer is yes. again, i would also like _ speaker, the answer is yes. again, i would also like to _ speaker, the answer is yes. again, i would also like to be _ speaker, the answer is yes. again, i would also like to be tribute - speaker, the answer is yes. again, i would also like to be tribute to - speaker, the answer is yes. again, i would also like to be tribute to the l would also like to be tribute to the families in what is truly a shocking report. can i ask the secretary of state, in addition to the issues identified around the culture in this particular trust, are the recommendations in terms of governance and boards, boards have key role in holding their executive to account and will he on that point be writing to boards to make them aware of their responsibilities about that and could i also ask what the implications are for the

national clinical audit of the confidential inquiries for maternal and infant deaths? in confidential inquiries for maternal and infant deaths?— confidential inquiries for maternal and infant deaths? in terms of the latter art and infant deaths? in terms of the latter part of _ and infant deaths? in terms of the latter part of a _ and infant deaths? in terms of the latter part of a question, - and infant deaths? in terms of the latter part of a question, the - latter part of a question, the national clinical audits, i will write to her about that. on her important point about boards, she is right, this final report talks about the importance of boards and making sure the people on the boards are vetted and understand their responsibilities and have the information they need to carry out these responsibilities. it is my understanding this cqc also change the rules around board members for nhs trust, requiring them to meet a new fitness test. it is nhs trust, requiring them to meet a new fitness test.— new fitness test. it is impossible to think about _ new fitness test. it is impossible to think about these _ new fitness test. it is impossible to think about these lost - new fitness test. it is impossible to think about these lost babies | new fitness test. it is impossible i to think about these lost babies and lost lives and damaged families without getting upset and angry but the work i have been doing with midwives and families in the last six months or so shows me that this

is notjust one trust. we had thousands of midwives marching on the street. we had the pandemic where mums were taking to social media, feeling marginalised and unheard and midwives saying they did not want to speak out because they did not want to frighten the mums and dads in their charge which is why they often feel they are not hurt themselves. we have got to help them because how is the nhs and the government going to reassure pregnant women and help the midwives reassure pregnant women given all of this in the news at the moment, how can we improve other maternity services are failing? she can we improve other maternity services are failing?— can we improve other maternity services are failing? she makes a very important — services are failing? she makes a very important point. _ services are failing? she makes a very important point. there - services are failing? she makes a very important point. there are l very important point. there are hundreds and thousands of births in the nhs each year and the vast majority of them are completely

safe, as i found for myself and many honourable members in this house also. what we have heard about today as when it goes wrong it goes tragically wrong and especially when it was avoidable, she is right to talk about the importance of other trusts in this, this is focused on one trust but we know already there was a problem in morecambe bay and there is an investigation in east kent as well. so there is action pro—choice and that is white is very important that the nhs acts on the recommendations for the wider nhs and i act on the recommendations for my department and we will certainly be doing that. flan my department and we will certainly be doing that-— be doing that. can i thank the secretary _ be doing that. can i thank the secretary of _ be doing that. can i thank the secretary of state _ be doing that. can i thank the secretary of state for - be doing that. can i thank the secretary of state for his - secretary of state for his statement, not one person could help but be moved top and dealing with

this horrific situation. i want to commend all involved in the ockenden report for their work on this issue. our hearts break for the little babies, mums, dads and family units who have been impacted by these horrendous practices and today we commend the bravery of the families who had the courage to speak out. giving the findings and the negative cloud that will be overall of those who work in maternity services, will the secretary of state take the opportunity to thank maternity teams throughout the united kingdom is who daily bring new life into this world with compassion and a professional manner. i think of the wonderful services in my own constituency hospital and i know today they will be saddened by what they are hearing in terms of this report. i will

warmlyjoin the honourable lady in thanking and commending the work of maternity teams who throughout the united kingdom for what they do day in and date, especially through the last two years through the pandemic making it even harder than usual. i know that many of them working will welcome this report because they will want to see the changes that are set out in this report. mr speaker. _ are set out in this report. mr speaker. i — are set out in this report. ii speaker, i would also like to thank the families for shining a spotlight on this. one of my children suffer from oxygen deprivation at birth from oxygen deprivation at birth from which i overs failure is in my care. the gp practice i was registered with had a wonderful community midwife who was with me through my pregnancy and the first birth of my daughter educated me afterwards. i was listening to, supported and i felt safe. whilst i

thank my right honourable friend for taking on board the recommendations, would he agree with me that every woman deserves that continuity of care that can make a profound difference. they will have somebody by their side who understands them, they do not have to go through the medical history over and over again, often missing out vital pieces. we should have loftier ambitions. will my right honourable friend try it at every woman will have that opportunity to have their own midwife with them all the way? yes. midwife with them all the way? yes, i a u ree midwife with them all the way? yes, i agree very — midwife with them all the way? yes, i agree very much — midwife with them all the way? yes, i agree very much with _ midwife with them all the way? yes, i agree very much with my honourable friend and i thank herfor sharing her own valuable experiences and she is right to talk about the importance of continuity of care which is part of the transformation package. i which is part of the transformation naackae. . ~ which is part of the transformation nackaue. ., ~' ,, . which is part of the transformation nauckae. ., ~' ,, . ., , ., package. i thank the secretary of state for the _ package. i thank the secretary of state for the report _ package. i thank the secretary of state for the report and - package. i thank the secretary of state for the report and it - package. i thank the secretary of state for the report and it is - package. i thank the secretary of state for the report and it is with | state for the report and it is with sadness we have to have report such as this in front of the house but in

doing so, i want to highlight point in relation to two something about it. those within the system and there are many good people with working in our nhs, unfortunately probably the majority of people out there for the right people —— reasons but unfortunately due to a process or culture of institutional blindness being mentioned earlier or bullying, they cannot whistle—blower and whistle—blowers are not being protected and as a consequence more and more of these types of reports are going to be required, not perhaps to do with maternity services but other services because whistle—blowers are being targeted and put down. i would ask whistle—blowers are protected and had the opportunity to have their concerns understood and heard. iie had the opportunity to have their concerns understood and heard. he is absolutely right _ concerns understood and heard. he is absolutely right and _ concerns understood and heard. he is absolutely right and one of the reasons we are creating a special

health board referred to earlier is to provide that independence and more protection for members of staff to come forward. members of staff for the first time will be able to report things they are concerned about directly to the board and they will have the right to investigate. many members from across the house have mentioned the incredible bravery of all the parents before for their babies, rhiannon davies. she now lives across the from wales but there are many women in mid wales who need to access the shrewsbury hospital and i am concerned they will hear the report today and will worry about the care they might be receiving over the next few days so as well as implementing the ockenden report info, will the secretary of state give his reassurance to women in wales who need —— who have no need to travel across the border? yes, i

can give that reassurance. i know that donor organs and in doing her work looks at cases from wales as well. —— donna ockenden in doing her work. well. -- donna ockenden in doing her work. . , well. -- donna ockenden in doing her work. ., , ., ., ., ,, work. can i first of all thank the secretary _ work. can i first of all thank the secretary of _ work. can i first of all thank the secretary of state _ work. can i first of all thank the secretary of state for _ work. can i first of all thank the secretary of state for his - work. can i first of all thank the - secretary of state for his statement and for his obvious compassion he has for all those involved and his support of the ockenden report. i put on record my sympathy to all of those parents who still grieve their laws and to whom no report will ever soothe the pain. will the secretary of state can —— confirm that this report will be made available to all hospital trusts across the united kingdom, including northern ireland to ensure lessons learned and 80 for recommendations of the report can be understood and can be emplaced

uk—wide. understood and can be emplaced uk-wide. , .., understood and can be emplaced uk-wide. , .. ., uk-wide. yes, i can give him that assurance. _ uk-wide. yes, i can give him that assurance, indeed _ uk-wide. yes, i can give him that assurance, indeed with _ uk-wide. yes, i can give him that assurance, indeed with the - uk-wide. yes, i can give him that i assurance, indeed with the northern ireland health service we are more than happy to reach out and work proactively with them and improving maternity services in northern ireland as well. i maternity services in northern ireland as well.— ireland as well. i would like to thank my _ ireland as well. i would like to thank my right _ ireland as well. i would like to thank my right honourable - ireland as well. i would like to i thank my right honourable friend ireland as well. i would like to - thank my right honourable friend for a statement and all the many members present who contributed to the process that has led to the report and following remarks by my honourable friend, i have been working with the member for moray combination who is sadly on important constituency business and cannot be here today to look at the nature of this inquiry and mine and others on the welsh border so will my right honourable friend reflector will be many concerned residents in wales, alongside the victims in the

report, who need representation on this important issue? yes. report, who need representation on this important issue?— report, who need representation on this important issue? yes, and i can uive m this important issue? yes, and i can give my honourable _ this important issue? yes, and i can give my honourable friends - this important issue? yes, and i can give my honourable friends that - this important issue? yes, and i can| give my honourable friends that very assurance he is seeking. mr; give my honourable friends that very assurance he is seeking.— assurance he is seeking. my right honourable _ assurance he is seeking. my right honourable threads _ assurance he is seeking. my right honourable threads said - assurance he is seeking. my right honourable threads said in - assurance he is seeking. my right honourable threads said in a - honourable threads said in a statement that cqc only rated maternity services inadequate in 2018 which is unacceptable so can he ensure that the coc inspection are now rigorous enough that feelings are picked up much earlier to prevent this type of thing happening again? mr prevent this type of thing happening auain? ~ ,, ., ~' prevent this type of thing happening auain? ~ .,~ ., prevent this type of thing happening auain? ~ ., again? mr speaker, what i can assure my honourable _ again? mr speaker, what i can assure my honourable friend _ again? mr speaker, what i can assure my honourable friend is _ again? mr speaker, what i can assure my honourable friend is that - again? mr speaker, what i can assure my honourable friend is that there - my honourable friend is that there have been a number of changes already in the coc approach but i cannot give her the assurance that it has changed enough because this report has just been published and it is important to me to follow through and make sure where relevant

independent ratings are also making the changes set out in this report. to respond to the lady opposite, she was right to suggest an update from ministers on the progress of this report, i will make sure that happens and picks up on this very question about the coc as well. this question about the (qc as well. this house is united _ question about the cqc as well. this house is united in heartache over the lives lost and destroyed, of the women's island is and told to shut up. as an npi have concluded that nhs bureaucracy has systemic problems of sexism. i remember 36 hours in labour having already been rushed to the operating theatre, being denied a c—section and then being denied a c—section and then being rushed for a c—section on the because my husband noticed my son's heart rate had dropped. top because

that compromises care and it still happens in hospitals around this country across different types of care. . . ~' , country across different types of care. ., ., ~ , ., ., care. can i thank my honourable friend for saying _ care. can i thank my honourable friend for saying what _ care. can i thank my honourable friend for saying what she - care. can i thank my honourable friend for saying what she has i care. can i thank my honourable friend for saying what she has in the way she did and also talk about her own experience. she is absolutely right to emphasise the point the nhs is there caring for everyone, regardless of their gender but comes to women in particular, this is precisely why the government is right to want to set out and we will do so shortly, a very detailed winning strategy for the first time ever. . ~' winning strategy for the first time ever. ., ~ , ., ., winning strategy for the first time ever. ., ~ i. ., _, . , ever. thank you. that concludes the proceedings — ever. thank you. that concludes the proceedings on _ ever. thank you. that concludes the proceedings on that _ ever. thank you. that concludes the proceedings on that statement - ever. thank you. that concludes the proceedings on that statement and l ever. thank you. that concludes the i proceedings on that statement and we will now— proceedings on that statement and we will now move to the next item of business — will now move to the next item of business i— will now move to the next item of business. i will delay for a moment to allow_ business. i will delay for a moment to allow members to quietly and quickly— to allow members to quietly and quickly leave the chamber. those who are coming _ quickly leave the chamber. those who are coming for the next item

a lovely day today but for some of you those temperatures dropping by 11 in manchester. it certainly feels cold and there are some snow showers

around. often when we do manage