Bear with me here – this thread will make sense if you follow it (I hope!)

My baby daughter, Kate, died in 2009.  

The coroner said we couldn’t have an inquest.

We needed an inquest to learn why she had died as it was seemingly inexplicable.

We therefore had to legally challenge him.

After the inquest in 2012, (the one the coroner said we couldn’t have), Kate’s death was unequivocally proven to have been avoidable by a unanimous jury verdict.

The hospital trust (Shrewsbury and Telford) refused to accept these findings.  

We needed them to accept the findings to embed identified learning for the prevention of future deaths.

We had to legally challenge them.

In 2015, after the Parliamentary and Health Service Ombudsmen finally reviewed our challenge, they forced the hospital trust to accept the inquest’s findings.

In 2016, after saying they had made all required changes after being forced to accept the inquest’s findings, Kayleigh’s baby daughter Pippa died.

The circumstances around and after Pippa’s death, in terms of the way concerns raised were mishandled and incidents were incorrectly categorised, were a carbon copy of events in Kate’s case dating back to 2009.

In other words, despite everything we went through, nothing had changed after Kate’s death for the prevention of future avoidable deaths.

We had to challenge this status quo.

This is why Kayleigh, Colin, Richard, and I researched and identified 23 cases with similar patterns of failures having contributed to the avoidable catastrophic harm or deaths of babies or mothers at the trust.  

We gave the evidence to then health secretary Jeremy Hunt in late 2016 and asked for an inquiry into the trust.

He agreed to review the cases but not seek an inquiry.

We had to have an inquiry to get answers for the hundreds of other families affected, to identify required changes and to create the actions for improvement for the prevention of future harm.

We had to challenge him.  

Finally, after Hunt capitulated in the face of our challenge because of further evidence we submitted, in 2022, that inquiry was concluded by Donna Ockenden.  Hundreds of cases of harm and death were assessed by her incredible team, and the learning from them all created a blueprint for required change across England’s maternity landscape.  Change that will save babies and mothers from harm and death.

If you’ve stayed with the thread this far well done.

My point is, it took a very long time to achieve required change, and we had to overcome many hurdles on the journey whilst battling lifelong, at times crippling grief, maintaining a career, raising children…and yet it doesn’t have to be this hard.

If we had been listened to at each step along the path we would have achieved required change far sooner and so many more lives would have been saved.

We four met with the CQC today.  

It’s fair to say they had a separate agenda to ours and we failed to find common ground on most points discussed (the subject of a future update perhaps.)  

However, however, however.

We have taken a tentative first step on our path towards national learning and the creation of a national plan of action.  A plan of action that will take a child from pre-conception though their early years of life healthily and within a well-supported network.  Because the CEO of the CQC, Ian Trenholm listened to one thing we said.  He listened to the fact that if all four nations work together, time can be saved, ideas can be shared, learning can be identified, and change can happen more quickly.

Instead of ignoring what we are evidencing and continuing to exist under a rock of assumption that sufficient positive headway is being made, Mr. Trenholm suggested the four nations’ regulators could potentially form an ‘alliance’ and work together.

Therefore, step one on the path to changing the state of all Britain’s nations’ maternity and early years’ services has been taken today.  It won’t take 100 years to make progress and effect change if all others we have reached out to, i.e., the politicians responsible for healthcare in Wales, Scotland, Northern Ireland and England, also give their support to us four as we call for a national – four nation – inquiry that gets to the root of all issues – including failures in regulation.  

And if they listen to us, and say ‘yes, we can do this’ we can turn the appalling, failing state of maternity and early years’ service provision around in less than a generation.  Because our children deserve a better, safer journey to parenthood, and their children deserve a better start in life.  

If you agree, please sign our petition.

Let us hope Mr. Trenholm makes good on his assurance that he will lead on the formation of an alliance between all nations’ regulators.