Tag: Nadine Dorries

The statement made by Nadine Dorries, the Minister for Patient Safety, Suicide Prevention and Mental Health, in the House of Commons on 10 June 2021.

I would like to inform the House of the launch of a public consultation on proposed legislative provisions governing the appointment and operation of the patient safety commissioner for England.

As my colleagues will be aware, on 14 December 2020, the Government tabled an amendment to the Medicine and Medical Devices Bill to establish an independent patient safety commissioner for England. The Medicines and Medical Devices Act 2021 (MMD Act) achieved Royal Assent on 11 February 2021 and on 11 April established the commissioner position and its main duties and powers.

The introduction of a patient safety commissioner also acts on the second recommendation of the independent medicines and medical devices safety review, “First Do No Harm”, published in July 2020 by Baroness Cumberlege.

The patient safety commissioner will add to and enhance the existing work that has been done to improve patient safety by acting as a champion for patients. Listening to our patients is integral to our healthcare system and the commissioner will help to make sure patient voices are heard.

The core duties of the commissioner are to promote the safety of patients in the context of the use of medicines and medical devices and to promote the importance of the views of patients and other members of the public in relation to the safety of medicines and medical devices.

Under the MMD Act 2021, (paragraph 6 of schedule 1) the Secretary of State is able to make legislative provisions about the appointment and operation of the commissioner, for example, the terms of office, finances and other support for the commissioner. As is required by the MMD Act, the Department has launched a public consultation to gather views from interested persons on the detail on the appointment and operation of the commissioner. Consultation responses will be carefully considered and will feed into the required secondary legislation.

This consultation will help to ensure that the provisions governing the appointment and operation of the patient safety commissioner are as comprehensive as needed, so that the commissioner will be able to work for, with and in the best interests of patients.

I would like to take this opportunity to reassure the House that the Government continue to prioritise work on this initiative. The launch of this consultation represents good progress in setting up of the commissioner.

The consultation can be accessed using the following link:

https://www.gov.uk/government/consultations/the-appointment-and-operation-of-the-patient-safety-commissioner.

The comments made by Nadine Dorries, the Minister for Patient Safety, Suicide Prevention and Mental Health, in the House of Commons on 25 May 2021.

Today, I am pleased to announce the launch of the Government’s consultation on the statutory guidance for the Mental Health Units (Use of Force) Act 2018.

The Mental Health Units (Use of Force) Act 2018, also known as Seni’s Law, was introduced into the House of Commons by the hon. Member for Croydon North (Mr Reed) in July 2017 and received Royal Assent in November 2018. The Act is named after Mr Olaseni Lewis, who died as a result of being forcibly restrained while he was a voluntary patient in a mental health unit.

The purpose of the Act is to clearly set out the measures which are needed to both prevent the use of force and then ensure accountability and transparency about the use of force in mental health units. By promoting good practice, identifying poor practice, and through a greater understanding of where there are problems or issues for specific groups, we can address this nationally as well as locally. The statutory guidance sets out how we expect mental health units to meet the requirements of the Act. This consultation will seek views on the clarity, content and approach of the proposed guidance.

This is vitally important to minimise restrictive interventions in mental health units which affected 12,000 individuals in 2019-20, and disproportionately those with protected characteristics under the Equality Act 2010.

This is a landmark piece of legislation which enjoys the support of patients, people with lived experience, voluntary and charitable sector organisations and the NHS. Today’s launch represents a significant step forward in our efforts to prevent the use of force in mental health units which would not have been possible without the tireless campaigning of the hon. Member for Croydon North and the Lewis family.

This consultation is part of the Government’s wider reform agenda to improve support for individuals with severe mental illnesses. The Government published their Mental Health Act White Paper on 13 January 2021, which sets out proposals for once in a generation reforms to the Mental Health Act, responding to and building on Sir Simon Wessely’s review of the Act. We are also working hard to achieve our NHS long-term plan commitment to give 370,000 adults and older adults with severe mental illnesses greater choice and control over their care and support them to live well in their communities by 2023-24.

The consultation will conclude on 17 August 2021. The Government’s intention is to publish the final statutory guidance and begin commencement of the Act in November 2021.

The statement made by Nadine Dorries, the Minister for Patient Safety, in the House of Commons on 11 January 2021.

The report of the Independent Medicines and Medical Devices Safety Review (IMMDS Review) was published on 8 July last year. I would like first to sincerely thank Baroness Cumberlege and her team for their work on the review. I also pay tribute to the women and their families who bravely shared their experiences and brought these issues to light. Without their tireless efforts to have their voices heard, this review would not have been possible.

The overriding question investigated by the review is how the health and care system listens and responds to patient concerns raised by patients, and women in particular. We must not forget that the Cumberlege review, alongside other independent inquiries including the Paterson inquiry, was commissioned because women did not feel listened to or their concerns acknowledged—today is another step towards righting this.

On the Paterson inquiry, I would also like to provide a very brief update. Work on the Government response was temporarily paused last spring due to the first wave of the covid-19 pandemic. Efforts have since resumed at pace, and I can confirm today that I will announce and publish the Government’s initial response in Parliament shortly.

Returning to the IMMDS review, many of the report’s recommendations have already been discussed in detail during the Committee stage of the Medicines and Medical Devices Bill, and this has helped us to determine our future direction. We are very grateful to Members from both Houses who have worked with us on this.

I am today updating the House on the Government’s response to the report of the IMMDS review, taking each recommendation in turn.

Recommendation 1: The Government should immediately issue a fulsome apology on behalf of the healthcare system to the families affected by Primodos, sodium valproate and pelvic mesh.

In July, when I introduced this report to the House, I made an unreserved apology on behalf of the health and care system to those women, their children and their families for the time the system took to listen and respond. I assure those affected that the Government have listened, and will continue to listen.

Recommendation 2: The appointment of a Patient Safety Commissioner who would be an independent public leader with a statutory responsibility. The Commissioner would champion the value of listening to patients and promoting users’ perspectives in seeking improvements to patient safety around the use of medicines and medical devices.

The central recommendation in the report is for the establishment of an independent Patient Safety Commissioner. This recommendation has rightly ignited much interest and debate in both Houses, and the Government have listened carefully to the arguments made for a Commissioner, and how this might sit within the wider patient safety landscape.

Patient safety is a key priority for the healthcare system. In my role as Minister of State for patient safety, I often hear from and meet with people who have been affected by issues of patient safety. Their stories have common themes—of suffering avoidable harm, of not being listened to—and of a system that is then difficult to navigate when things go wrong. We want to make the NHS as safe as anywhere in the world, and we must retain an absolute focus on achieving this goal.

I can therefore confirm that the Government tabled an amendment to the Medicines and Medical Devices Bill before the Christmas recess to establish the role of an independent Patient Safety Commissioner, in line with Baroness Cumberlege’s second recommendation.

The Commissioner will act as an independent advocate for patients, and strengthen the ability of our health services to listen to the voice of patients. The Commissioner will be established as a statutory office holder, appointed by the Secretary of State for Health and Social Care, and will act independently on behalf of patients.

The Commissioner’s core duties will be to promote the safety of patients and the importance of the views of patients in relation to medicines and medical devices. To help in carrying out these duties, the Commissioner will have a number of powers and functions, including the ability to make reports and recommendations to the NHS and independent sector, and to request and share information with these bodies.

The Government look forward to working with Members of both Houses to ensure this new post acts as a beacon for listening and reflecting the safety concerns of patients, so that we can drive positive culture change in our healthcare system.

Recommendation 3: A new independent Redress Agency for those harmed by medicines and medical devices should be created based on models operating effectively in other countries. The Redress Agency will administer decisions using a non-adversarial process with determinations based on avoidable harm looking at systemic failings, rather than blaming individuals.

The Government have no current plans to establish a redress agency as set out in recommendation 3. The Government and industry have previously established redress schemes without the need for an additional agency.

Recommendation 4: Separate schemes should be set up for each intervention—HPTs, valproate and pelvic mesh—to meet the cost of providing additional care and support to those who have experienced avoidable harm and are eligible to claim.

Recommendation 4 on redress schemes for sodium valproate, mesh, and HPTs remains under consideration.

Recommendation 5: Networks of specialist centres should be set up to provide comprehensive treatment, care and advice for those affected by implanted mesh; and separately for those adversely affected by medications taken during pregnancy.

Good progress is being made on establishing specialist mesh services, which are the fifth recommendation in the report. NHS England is working with NHS hospitals to establish specialist mesh services which are currently planned to go live from the spring this year.

These services will bring together leading experts to provide multidisciplinary care and treatment for all women who have experienced complications due to vaginal or abdominal mesh procedures.

With a centre in every NHS region, these new services will ensure nationwide provision, and centres will work together to hone their expertise and share best practice.

We continue to consider the second part of recommendation 5, which is for specialist centres for those adversely affected by medicines in pregnancy.

Recommendation 6: The Medicines and Healthcare products Regulatory Agency (MHRA) needs substantial revision particularly in relation to adverse event reporting and medical device regulation. It needs to ensure that it engages more with patients and their outcomes. It needs to raise awareness of its public protection roles and to ensure that patients have an integral role in its work.

Patient safety is the MHRA’s top priority. The MHRA recognises that the major changes highlighted by the report, particularly recommendation 6, are very important.

The MHRA has already begun a substantial programme of work to improve how it involves patients in all aspects of its work, to reform systems for reporting adverse incidents with medicines and medical devices, and to strengthen the evidence base for its regulatory decisions.

Within the MHRA’s work to strengthen the evidence base, the safety of medicines in pregnancy is of utmost importance.

In the UK, three quarters of a million babies are born each year, and more than half of expectant mothers will need to take medicines when pregnant. We must ensure that women have high-quality, accessible information to be able to make informed decisions about their healthcare.

To that end, I would like to highlight two important developments of MHRA reform.

Firstly, the MHRA expert working group on optimising data on medicines used during pregnancy is today publishing its report which recommends ways in which healthcare data can be better collected and made available for analysis. This will enable the generation of better evidence on medicines used in pregnancy and will be vitally important when developing clear and consistent advice for women.

Second, the MHRA has established a safer medicines in pregnancy and breastfeeding consortium. This brings together 16 leading organisations from across the NHS, regulators, and key third sector and charitable organisations. Today, they are launching a strategy setting out how they will work to improve information on medicines for women who are thinking about becoming pregnant, are pregnant, or are breastfeeding.

Sodium Valproate

On sodium valproate, in response to concerns raised during the previous debate on the IMMDS review, I am pleased to announce that the National Director of Patient Safety has recently established a Valproate Safety Implementation Group.

This Valproate Safety Implementation Group will drive forward work to reduce harm from valproate through taking action to reduce the number of women prescribed valproate, and improving patient safety for women for whom there is no alternative medication, for example by increasing adherence to the Valproate Pregnancy Prevention Programme. The programme will ensure that every girl or woman knows about the risks of valproate in pregnancy, that where appropriate she is on effective contraception, and that she has a review by her specialist prescriber at a minimum once a year, when a risk acknowledgement form will be discussed and signed by both prescriber and woman herself. Importantly, the Valproate Safety Implementation Group will work with patients to understand how women can be supported to make informed decisions about their health care.

In addition, last week the MHRA published the conclusions of a safety review into antiepileptic drugs conducted by the Commission on Human Medicines. This will help clinicians identify safer alternatives to valproate for the treatment of epilepsy in women who may become pregnant.

I am also pleased to announce that the first data from the new Valproate Registry will become available later this month. The registry is being developed by the MHRA and NHS Digital, and will support work to monitor adherence to the Valproate Pregnancy Prevention Programme, and allow for long-term individual patient follow up.

Recommendation 7: A central patient-identifiable database should be created by collecting key details of the implantation of all devices at the time of the operation. This can then be linked to specifically created registers to research and audit the outcomes both in terms of the device safety and patient reported outcomes measures.

The seventh recommendation in Baroness Cumberlege’s report rightly reflects on the importance of collecting the right data for monitoring the safety of medical devices. We recognise the need for improved data collection and analysis for medical devices.

That is why the Government acted in June last year to amend the Medicines and Medical Devices Bill to create the power to establish a UK-wide medical device information system prior to the review report being published, as we recognised the need to deliver such an information system. This system will mean that in future, subject to regulations, we can routinely collect medical device, procedure and outcome data from all NHS and private provider organisations across the UK, ensuring that no patient in the UK falls through the gaps.

The Government are grateful to Members in both Houses, including Baroness Cumberlege, for their support for establishing a medical device information system.

Recommendation 8: Transparency of payments made to clinicians needs to improve. The register of the General Medical Council (GMC) should be expanded to include a list of financial and non-pecuniary interests for all doctors, as well as doctors’ particular clinical interests and their recognised and accredited specialisms. In addition, there should be mandatory reporting for the pharmaceutical and medical device industries of payments made to teaching hospitals, research institutions and individual clinicians.

The Government are considering recommendation 8, which is that doctors’ financial and non-pecuniary interests should be declared and publicly available.

Any publication of declarations of interest should cover all clinical decision-making staff, not just doctors: it would also need to be held where patients could most easily access and interpret the information, with appropriate governance arrangements. We will consider these issues in discussion with the GMC, other stakeholders and the patient reference group to ensure the views of patients are listened to and incorporated.

Recommendation 9: The Government should immediately set up a task force to implement this review’s recommendations. Its first task should be to set out a timeline for their implementation.

The Government have no plans to establish an independent taskforce to implement the report’s recommendations. A cross-system working group has already been set up, meeting regularly, to develop the Government’s detailed response to the report.

However, the Government recognise the need for effective patient engagement both to build trust, and ensure effective implementation. I am pleased to announce today that we are establishing a Patient Reference Group, which is part of Baroness Cumberlege’s ninth recommendation. The Patient Reference Group will ensure that patient voices are heard as we move forward towards a full response to the report.

Conclusion

The report of the IMMDS review powerfully demonstrates the importance of hearing the patient voice in patient safety matters. The actions outlined here demonstrate the Government’s commitment to learning from this report, and will support vital work already underway to hear the voice of the patient as part of the NHS Patient Safety Strategy. We currently plan to respond further to the report of the IMMDS review during 2021.

The statement made by Nadine Dorries, the Minister for Patient Safety, Suicide Prevention and Mental Health, in the House of Commons on 10 December 2020.

With permission, Madam Deputy Speaker, I would like to make a statement on the initial report from the Ockenden review, which was published this morning.

Before I update the House on the findings, I wish to remind the House of the tragic circumstances in which the review was established. It was requested by the Government following concerns raised in December 2016 by two bereaved families whose babies had sadly died shortly following their birth at the Shrewsbury and Telford Hospital NHS Trust. I am grateful to my right hon. Friend the Member for South West Surrey (Jeremy Hunt), who, as Secretary of State for Health and Social Care, asked NHS Improvement to commission the independent inquiry.

The inquiry is chaired by senior registered midwife Donna Ockenden, a clinical expert in maternity who was tasked with assessing the quality of previous investigations and how the trust had implemented recommendations relating to newborn, infant and maternal harm. As the report acknowledges, this year the country has rightly united in pride and admiration for our NHS, but we must accept that in the past not everyone has experienced the kindness and compassion from the NHS that they deserved.

The review team has met face to face with families who have suffered as a result of the loss of brothers and sisters, or who have, from a young age, been carers to profoundly disabled siblings. The team has also met parents in cases where there have been breakdowns in relationships as a result of the strain of caring for a severely disabled child or the grief after the death of a baby or resultant complications following childbirth.

The original terms of reference for the review covered the handling of 23 cases; however, since its launch more families have come forward and extra cases have been identified by the trust. As a result, the review now covers 1,862 cases, and this has led to an extension of its scope and delivery. An interim report has therefore been published today, and it contains a number of important themes that the review team believe must be shared across all maternity services as a matter of urgency. Indeed, I personally, and the Government, pushed to have this interim report at this point in time so that we could learn from the findings of the inquiry so far.

This is the first of two reports, based on a review of 250 cases between 2000 and 2018; the second, final report will follow next year. Today’s report makes it clear that there were serious failings in maternity services at the Shrewsbury and Telford Hospital NHS Trust. I would like to express my profound sympathies for what the families have gone through. There can be no greater pain for a parent than to lose a child. I am acutely aware that nothing I can say today will lessen the horrendous suffering that these families have been through and continue to suffer. Nevertheless, I would like to give my thanks to all the families who agreed to come forward and assist the inquiry.

The review team held conversations with more than 800 families who have raised serious concerns about the care they received. I know that it has not been easy for them to revisit painful and distressing experiences, but through sharing their stories we can ensure that no family has to suffer the same pain in the future. From the outset the inquiry wanted families to be central to the team’s work and for their voices to be heard, and I am pleased that the families were able to see the report first, this morning, shortly before it was presented to Parliament. I assure them, and Members of this House, that we are taking today’s report very seriously and that we expect the trust to act on the recommendations immediately.

I thank Donna Ockenden and her team for their diligent work. Their valuable work provides essential and immediate actions to improve patient safety and ensure that maternity services at the trust are safe. Four of those actions are for the trust and seven are for the wider maternity system. The report sets out clear recommendations for what the trust can do to improve safety relating to overall maternity care, maternal deaths, obstetric anaesthesia and neonatal services.

The report also sets out actions that can make a difference to the safe provision of maternity services everywhere. They include recommendations on enhancing patient safety and how we can best listen to women and families, developing more effective staff training and ways of working, managing complex pregnancies and risk assessments throughout pregnancies, monitoring foetal wellbeing, and ensuring that patients have enough information to give informed consent. I welcome those recommendations and the others in the report. We will be working closely with NHS England, NHS Improvement and Shrewsbury and Telford Hospital NHS Trust, which have accepted each of the recommendations and will take them forward. We learn from these tragic cases so that we can give patients the safe and high-quality care that they deserve.

Patient safety is a big priority for me and the Government. We want the NHS to be the safest place in the world to give birth, and this report makes an important contribution towards that goal. Our ambition is to halve the 2010 rates of stillbirths, neonatal and maternal deaths, and brain injuries in babies occurring during or soon after birth by 2025. We have achieved early our ambition of a 20% decrease in stillbirths by 2020, but of course there is always more to do and we owe it to the families to get it right.

The Ockenden review is an important document that vividly shows the importance of patient safety. I assure the House that we will learn the lessons that must be learned so that the tragic stories found within these pages will never be repeated again. I commend this statement to the House.

The statement made by Nadine Dorries, the Minister for Patient Safety, Mental Health and Suicide Prevention, in the House of Commons on 26 November 2020.

Today we have published the report into the events surrounding the death of Elizabeth Dixon—a baby who sadly died in December 2001 from asphyxiation resulting from a blocked tracheostomy tube and while under the care of a private nursing agency.

I offer my heart-felt condolences to Elizabeth’s family, to Anne and Graeme Dixon for their loss, compounded by the length of time—the passage of 20 years—before the facts of this case have been brought to light.

The investigation led by Dr Bill Kirkup was tasked with reviewing the care given to Elizabeth Dixon between her birth on 14 December 2000 and her death on 4 December 2001—and the response of the health system to a catalogue of errors and serious failings in that care.

This report describes a harrowing and shocking series of mistakes associated with the care received by Elizabeth and a response to her death that was completely inadequate and at times inhumane. Elizabeth and her family were let down by a failure to diagnose or respond to her underlying condition, to put in place the care she required, to acknowledge the circumstances of her death or provide her parents with an honest account of these failings.

The investigation sheds light on what the report describes as a “20 year cover up”. It alleges that some individuals have been persistently dishonest in accounting for their actions or inaction.

Underlying all of this was the acceptance of a flawed prognosis that influenced the future course of events. It created a situation in which

“facts were wilfully ignored, and alternatives fabricated”.

Shocking too is the implication in the report’s recommendations that the presence of her physical and mental health needs may have been used to justify or excuse the inadequate care she had received.

On behalf of Government and the health system I would like to say I am truly sorry for the devastating impact this must have had upon the Dixon family.

Individuals made mistakes and acted unprofessionally, but the system allowed it. The report makes it clear that

“clinical error, openly disclosed, investigated and learned from, should not result in blame or censure; equally, conscious choices to cover up or to be dishonest should not be tolerated”.

It is also unacceptable for patients ever to be exposed to unsafe or poor care, and I remain fully committed to ensuring we provide the highest standards of quality and safe services to all patients.

I am grateful to my right hon. Friend the Member for South West Surrey (Jeremy Hunt) for commissioning this investigation in June 2017 when he was Secretary of State for Health and bringing these events into the open. I would also like to thank Dr Bill Kirkup and his team for the diligence and hard work that has informed their report.

Particularly, I would like to pay tribute to Anne and Graeme Dixon who have fought so hard for answers. I hope this report is the beginning of a process that will bring some closure for the family. They should not have had to wait for so long.

This report shines a light on a culture of denial and cover up 20 years ago that left a family with little choice but report their concerns to the police. Families should not have to fight a closed system for answers and I will not hesitate to expose this sort of behaviour whenever it appears today. Indeed, Elizabeth’s legacy should be that other families will always be told the truth.

Relevant organisations will need to consider and reflect carefully on the report’s recommendations. There is no room for complacency. The continual appearance of shocking reports about patient safety—historical or more recent—implies there is much for the NHS to focus on. My Department will therefore have oversight of their responses and report back to the House. There needs to be learning and implementation, but above all I want to be assured that we are doing all we can to make sure such events cannot happen again.

No other family should ever again have to go through the heartache and frustration experienced by the Dixons and I apologise again for the failings set out in this report.

Copies of the report have been laid before the House.

The comments made by Nadine Dorries, the Minister for Patient Safety, on 18 November 2020.

We are determined to make the NHS the safest healthcare system in the world. The introduction of digital prescribing systems has helped us reduce potentially deadly medication errors and save our hard-working staff valuable time, enabling them to dedicate their full attention and care to patients.

As we enter what is set to be a challenging winter, the best way we can continue to protect patients and staff is if we all work together and continue to follow the national restrictions to suppress the virus.

Below is the text of the statement made by Nadine Dorries, the Minister for Patient Safety, Mental Health and Suicide Prevention, in the House of Commons on 9 July 2020.

With permission, Mr Deputy Speaker, I would like to make a statement about the independent medicines and medical devices review. This review was announced by my right hon. Friend the Member for South West Surrey (Jeremy Hunt) in February 2018, in response to public concern about the safety of medicines and medical devices used by the NHS. It focused on three areas. The first is Primodos, a hormone-based pregnancy test that is claimed to have led to miscarriages and birth defects during the 1960s and ’70s. It was prescribed to more than 1.5 million women before it was withdrawn from use in 1978. The second is sodium valproate, an anti-epilepsy drug that has been definitively linked to autism and learning disabilities in children when taken during pregnancy. The third is the vaginal mesh implants used in the treatment of pelvic organ prolapse and stress urinary incontinence, which have been linked to crippling, life-changing side-effects.

Baroness Cumberlege was asked to conduct a review into what happened in each of those three cases, including whether the processes that were followed were sufficient when patients’ concerns were raised. She was also asked to make some recommendations for the future, such as: how to consider the right balance between the criteria or threshold for a legitimate concern; how best to support patients where there might not be a scientific basis for their complaint, but where they have still suffered; how we can enhance the existing patient safety landscape; and how we can be more open to the insights that close attention to patient experience can bring.

The report has now been published, and a copy has been deposited in the Library of the House. It makes for harrowing reading. Every page makes clear the pain and suffering that has been felt by so many patients and their families. As Baroness Cumberlege herself said, they suffered “avoidable harm”. She said that she had listened to the heart-wrenching stories of acute suffering, of families fractured, of children harmed and so much more.

On behalf of the health and care sector, I would like to make an apology to those women, their children and their families for the time the system took to listen and respond. I would also like to thank every single person who has contributed to the review. I know that some of them wanted to be here in the House today. They felt as though their voices would never be heard, but now they have been, and their brave testimony will help patients in the future. I have watched and read some of their testimonies. They left me shocked, but also incredibly angry and most of all determined to make the changes that are needed to protect women in the future. It is right and proper that the victims were the first people to see this report. As a Government, we have now received its findings and, as hon. Members will understand, we are taking time to absorb them before we respond. That is the least that the report deserves. We will update the House at the very earliest opportunity.

I would like to thank Baroness Cumberlege, who has carried out her work with thoroughness and compassion. She has worked tirelessly to ensure that patients and ​their families have been heard, and I would like to pay tribute to her and her team. I know that the patients’ stories that they have heard have been harrowing and, at times, frankly beyond belief. She has done us all a great service by highlighting them, along with the suffering of so many women and their families. I know that there will be strong feelings across the House about the report, and that hon. Members will be eager to hear a fuller response. However, it is imperative for the sake of those who have suffered so greatly that we give the review the full consideration that it absolutely deserves.

It is clear, as I am sure the whole House will concur, that the response to these issues from those in positions of authority has not always been good enough. The task now is to establish a quicker and more compassionate way to address issues of patient harm when they arise. We must ensure that the system as a whole is vigilant in spotting safety concerns, and that we rapidly get to grips with the concerns identified by the report. We must make sure that different voices are invited to the table and that patients and their families have a clear pathway to get their answers and a resolution. The issues tackled in this report are, from one perspective, complex—matters of regulation, clinical decision making and scientific judgment—but there is one simple core theme that runs through all of this, and it goes to the heart of our work on patient safety. It comprises just two words: listening and humility. So much of the frustration and anger from patients and families stem from what they see as an unwillingness to listen—for us to listen and for them to be heard. We need to make listening a much stronger part of clinical practice and to make the relationship between patients and clinicians a true and equal partnership.

While the review has been progressing, the Government and the NHS have taken a number of steps relating to the concerns it has raised. However, there is always more that we can do, and it is clear that change is needed. We owe it to the victims and their families to get this right. I commend this statement to the House.