MP to Lead Learning and Improvement Board After Maternity Service Failings
Michelle Welsh, a Member of Parliament and the government's first national maternity adviser, has been appointed to chair a new Learning and Improvement Board tasked with overseeing enhancements to maternity services at Nottingham University Hospitals (NUH) NHS Trust.
The appointment follows the publication of a critical independent review into NUH's maternity services, which revealed "deeply embedded systemic failures" that resulted in deaths and avoidable harm to mothers and babies.
NUH confirmed that Labour MP Michelle Welsh, whose son William was born initially unresponsive following delays by maternity staff, will chair the board.
Anthony May, chief executive of NUH, described the review's publication as a "watershed moment" and emphasized the importance of oversight in addressing the findings.
Background and Findings of the Nottingham Maternity Review
The independent maternity review, led by senior midwife Donna Ockenden, began in September 2022 and involved contributions from approximately 2,500 families and over 800 staff members.
The review identified "potentially avoidable" adverse outcomes in 520 cases involving mothers and babies. It found that different care might have changed the outcome in 260 cases, including 155 infant deaths and 105 instances of serious brain injury attributed to substandard care.
The review highlighted that the harm was seldom due to a single issue but rather multiple factors such as inadequate monitoring of babies, poor interpretation of fetal heart monitoring, failure to recognize fetal distress during labour, and failure to escalate cases to senior doctors.
Concerns raised by women were frequently dismissed or minimized, with staff reporting experiences of racism and "racist attitudes towards black women labelled too loud, too demanding." The review also found that trust leaders were aware of serious maternity service issues dating back to at least 2010 but failed to take appropriate action.
Additionally, the report identified a "bullying and toxic" workplace culture that discouraged staff from speaking up.
Families participated in a minute's silence to mark the conclusion of Donna Ockenden's speech at a press conference on Wednesday.
Required Actions and Board Formation
NUH has been provided with a list of mandatory actions to address the review's findings. These include urgent improvements in risk management and monitoring, enhancing neonatal safety and care, improving psychological support for families, and strengthening governance, leadership, and accountability.
Michelle Welsh, Sherwood Forest MP and appointed as the government's first maternity adviser in May, shared her personal experience of maternity care during the birth of her son in 2020. She was repeatedly advised not to attend the hospital, and her son was born not breathing. Initial assessments suggested he might have deafness and learning difficulties, which were later found to be inaccurate.
"The findings of the independent maternity review reinforce the urgent need for change in our maternity services. For that reason, I have agreed to chair the NUH Learning and Improvement Board. I acknowledge the suffering experienced by the families at the heart of this review, whose courage in speaking out has brought to light the desperate need for change. Having campaigned for improvements in maternity services for the past five and a half years, I am committed to working collectively with families, staff and partners to ensure lasting improvements are made."
Donna Ockenden paid tribute to families during the press conference.
Health Secretary James Murray described the review's revelations as "chilling" during a House of Commons address and welcomed Welsh's appointment as chair of the improvement board.
"This is a significant moment and recognises Michelle's tireless efforts campaigning to improve maternity and neonatal services, delivering real change for all families," he said.
The Learning and Improvement Board will be supported by two additional groups representing families and staff. Donna Ockenden will co-chair the family group alongside a family member.
"I am so pleased to be remaining in Nottingham to support the ongoing perinatal improvement journey at NUH. The development of the Learning and Improvement Board fulfils a promise made to families that there would be continued scrutiny and improvement of maternity services at the trust. Its creation is also important to the more than 800 current and former staff at the trust who have engaged with the review. I am so glad that this is also an opportunity for their voices to continue to be heard."
Family Reactions and Calls for Public Inquiry
Families affected by the failings at NUH have emphasized the need for the actions to be taken "with the utmost seriousness" and have called for a statutory public inquiry across England.
Kim Errington, whose son Teddy died at Nottingham City Hospital in November 2020 at one day old, stated that an inquest found "undoubted failings" in his care. She expressed skepticism about the sufficiency of the improvement board alone.
"I can't help but be cautiously sceptical. I know that these things have to be put in place but the bottom line is we need a public inquiry to get to the real root of these issues and prevent it happening again. Anything that can happen alongside that, great, but don't do it as a standalone thing," she said.
Kim Errington said although the board was chaired by "fantastic people", it alone would not "solve the problem".
NUH Trust's Response and Future Plans
NUH has been under scrutiny for maternity failings prior to the review and has paid £117 million in compensation, in addition to receiving two record fines following prosecutions related to baby deaths.
The trust stated that the new board will provide an "independent check and challenge on the delivery of improvements."
Chief Executive Anthony May described the review's publication as an "important milestone in a journey that must continue."
"It is very important that we have robust, independent oversight of the implementation of the review's findings. We are committed to a comprehensive and sustained response to every action. Two years ago, we made a public commitment to ensure continued scrutiny of our maternity services, and this board is a key part of delivering on that promise. In the coming weeks, we will publish a detailed action plan setting out how every action will be addressed, with clear timescales and named accountability. We will continue to involve families and staff in shaping our response, and in holding us to account. We will work closely with the Learning and Improvement Board, NHS England, our regulators, commissioners, local families, partners and maternity experts to ensure improvements are delivered and sustained."
The trust also indicated that the board's terms of reference will be developed in collaboration with families, staff, and stakeholders, with the first meeting scheduled for later in the year. Progress updates will be shared publicly on a regular basis.
Additional reporting by Verity Cowley.
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