Just when you were certain you’d heard the last from us … we’re back!

Kayleigh and I spent too many nights in 2024 working on the most comprehensive map, data capture and case by case analysis of every single case of avoidable harm and preventable death in maternity for every hospital in each NHS trust in Scotland, England, Northern Ireland and Wales.  We even included private hospitals.

Whilst we went back to 1996 and mapped outliers in terms of extreme harm or extreme negligence – or, amazingly, extreme learning – the majority of cases we have catalogued are from 2009 to date.

But why?

Because no one else has.  Yes, MBRRACE-UK catalogue a lot.  HSIB log selectively. The media harvests randomly - and coroners seem to step in ad-hocly.  But what we have worked to create is … horrifying and yet truly enlightening in terms of finding clusters, themes, immediate needs for intervention, learning points … and … well … yes, just that.  Learning for the prevention of avoidable harm and death.  AVOIDABLE harm and death.

The reason you haven’t had an update for a long time is manifold.  Doing the foregoing work with very full time jobs that we both care deeply about, around families we are comprehensively dedicated to – including a surviving daughter each with anxiety issues stemming from the deaths of their sisters – has taken every available second.  And then … I have to be honest – the erosion of mental wellbeing from researching each ‘case’ (each person’s life, harm, death) has been something I personally never anticipated needing to face.  The depths of despair have been plumbed.  

I lived through my hardest years campaigning for Kate – but then I was focussed on one case only.  I was self-employed and had no ambitions to attempt to pay a mortgage or have a life.  Then her sister came along and the gaps in between the campaigning were wide enough to get a ‘proper' job, which has turned into a brilliant career thanks to some epic employers.  A home and holidays – and happiness has happened!  But 2024’s research was brutal…and then…and then.

After SO MANY letters to Wes Streeting, Kayleigh, Colin, Richard and I were invited to a roundtable to talk about our experiences, (no thanks, if you don’t know why we keep doing the doing, it really doesn’t matter), our research and our recommendations for change (as well as the evidence within which those recommendations are deeply rooted).

Christmas was upon us, school holiday obligations, family and friends to see, work mates to get together with in thanks for the camaraderie – CHILDREN to prioritise…grief to compartmentalise.  But … thanks to the DoH’s willingness to let us work from home (take note Britain’s employers – HOW MUCH MORE CAN BE ACHIEVED WITH FLEXIBLE WORKING), we duly met.

So many moments from the meeting stand out.  Mr Streeting acknowledging how RIGHT we were for months and even YEARS before anyone else said it and that YES the CQC IS a basket case (his words).  His incredulity at the reach and depth of the research we have compiled - and his request to receive it.  He stated he is surrounded by researchers so we shouldn’t have had to do the work.  And he meant it.  But we DID have to.  We have had to walk every single step of the way for just the truth about what happened to Pippa and Kate to be uncovered – never mind justice (still not there – police cases ongoing - West Mercia Police are incredible).  

We had to walk every single step of the way to get the Ockenden Review into SaTH commissioned and advanced to include more families than the 23 we presented to former SoS for Health Jeremy Hunt as a snapshot of the failings.  And so why is anyone surprised we have had to walk every single step of the way (and we still have miles to go) to ensure - ENSURE - there is a complete review of maternity issues in ALL FOUR NATIONS…as well as a joined up approach – via social care, early years and education – to secure, safeguard and surpass all expectations for the next generation.  

The Nottingham Review families were promised a visit during the meeting - hope it helps in some way.  Another grieving mother’s words, through her tears, were – PLEASE GOD – heard.  She said “use us because we want to help…”

So, last night Mr Streeting followed up on the meeting … he said he was no longer satisfied with proposals already on the table for improvements and he has subsequently challenged the DoH and NHS England to create stronger action plans based on what we discussed.  But maybe he didn’t really believe me when I called him out - in front of everyone - for proudly sitting in front of the national flag for the United Kingdom yet not addressing the fact that ideas from the DoH in London and NHS England (location clue in the name) are not enough.  

He and his counterparts in Wales, Scotland and Northern Ireland have to park their egos and work together (for the record, at this stage, I don't think Wes Streeting is the problem here).  Otherwise we are NOT a united kingdom.  Learning and change can happen in England – good.  But believe me, the research shows Scotland, Wales and Northern Ireland will remain in the dark ages…babies' heads pulled off during botched forceps deliveries ... I won't share anymore ... but the physical and psychological harm being meted out to this day is horrific.

As for handing over our research with no commitment to continue to include us in every level of conversation about how change has to be designed, implemented, tested, challenged and advanced.  No.  Because we know far too much to be ignored.  We have so much critical learning that has to be harvested.  If he doesn’t ‘use us’ – as the other mother expressed – learning and change will fall so far short of what is required.

Please sign the petition if you haven't already - and thank you for caring about babies' and mothers' - and families' - lives.