Fatal Accident Inquiry (Response)
To ask the Scottish Government what its response is to the findings of the fatal accident inquiry for Lea Lamont, Ellie McCormick, and Mira-Belle Bosch, published on 14 March 2025, which suggest that the three child fatalities were avoidable.
I appreciate Meghan Gallacher’s raising this urgent question. The loss of a baby is devastating for any family, and I offer my sincerest apologies to the families for any failures in the system that has seen the tragic deaths of baby Lea, baby Ellie and baby Mira-Belle. As a father of four, my heart breaks to think of the unspeakable pain that those families will be suffering, especially as the fatal accident inquiry has flagged opportunities for their babies’ lives to have potentially been saved.
In that light, I thank those families for participating in the fatal accident inquiry. I simply cannot begin to imagine the pain of not only losing their child but having to relive that time through the investigation. I am also grateful to Sheriff Principal Anwar for her report. We are considering the findings carefully with the maternity community to ensure that the recommendations are acted on with the greatest urgency.
Indeed, NHS Lanarkshire and NHS Greater Glasgow and Clyde have already put in place a range of actions to deliver against the recommendations, and they have an on-going programme of work to deliver the safest care for mothers and babies. I have written to the chief executives of those boards seeking further assurances that actions are under way and that appropriate changes are happening at pace, and I have asked to be kept informed of progress.
I appreciate the response that the cabinet secretary has just provided, because the most heartbreaking conclusion of the inquiry is, of course, that the deaths of Lea, Ellie and Mira-Belle could have been avoided. My deepest sympathies go to the families who have been impacted by the inquiry findings.
While we cannot undo the pain and distress that those families have endured, we must ensure that their experiences lead to meaningful change. The report highlights defects in the system of working in hospitals, pointing to a lack of guidance for midwives in assessing preterm labour symptoms and a lack of effective means of flagging risks on hospital systems.
Given the inquiry’s recommendations, although I was listening closely to what the cabinet secretary has just said, what further assurances can the Scottish Government provide to pregnant women and families that those recommendations will be fully implemented in order to prevent similar tragedies in the future?
Again, I thank Meghan Gallacher for her question. To reassure her, I would be happy to provide, in writing, to her and to the Health, Social Care and Sport Committee, the Government’s response to all those recommendations. I believe that there is already progress on some of them, and more progress to come, which is currently being worked on, on others.
Meghan Gallacher is right—improving maternity safety is paramount, and I would like to reassure expectant mothers that maternity services in Scotland are very safe for both mothers and babies. Our world-leading Scottish patient safety perinatal improvement programme works with maternity services across Scotland to drive improvements in care for mothers and babies.
We are also working with Healthcare Improvement Scotland on the renewed approach to significant adverse event reviews, and we will update the maternity and neonatal guidelines to reflect the revised HIS guidelines. To improve the safety of maternity services, the Government has commissioned HIS to develop a set of maternity standards. The process has already started and we expect the standards to be published in late 2025.
As Meghan Gallacher will know, HIS is also now starting unannounced inspections of maternity services in order to give that additional level of assurance.
A written response from the cabinet secretary would be greatly appreciated.
Following the reviews that were conducted by the fatal accident inquiry, and its findings, there will be significant concern, anxiety and anticipation among women and families who are expecting. Can the Scottish Government provide assurance on the additional measures that are being considered to enhance that patient safety—I understand that the cabinet secretary has just outlined some of those—to improve oversight and address staffing levels in our maternity and neonatal services in order to alleviate those concerns?
The cabinet secretary has provided a timescale for that, but could he also consider whether any changes that have been made to neonatal services, in particular in relation to the downgrading at Wishaw general hospital, can also be taken into consideration, given the findings of the fatal accident inquiry?
Progress on that is already under way. The Government published guidance in 2021 for boards on how and when to undertake significant adverse event reviews in maternity and neonatal services. Those sit alongside Healthcare Improvement Scotland’s SAER process, in which there is a strong focus on being open and including affected families. We expect all boards to follow those guidelines to ensure that robust and timely reviews are undertaken.
As I said, I will follow up in writing with both Meghan Gallacher and the Health, Social Care and Sport Committee about the individual recommendations and the work that is under way through the Health and Care (Staffing) (Scotland) Act 2019. I would also be more than happy to interact with her, as I have with others, about the process for the reorganisation of neonatal services, which I believe will result in a safer process for the most vulnerable babies in our society.
I also thank the cabinet secretary for his answers.
Last year, a report on neonatal deaths recommended the review of maternity units to help to assess how care for mothers and babies can be improved. As the cabinet secretary said, following that, it was recommended that Healthcare Improvement Scotland carry out inspections of maternity units from January 2025 in order to provide assurances on the care that women and babies can expect to receive. Will the cabinet secretary provide an update to the Parliament on the progress that has been made on those inspections?
I thank Carol Mochan for her question. I can provide an illustrative update. The first inspections have happened, and we are expecting reports on them later this year. During the inspections, which are to last between one and three days, HIS inspectors will look at care, speak to staff and senior managers, talk to mothers and families, and review information about staffing levels, culture and leadership in the units.
I am happy to correspond further with Carol Mochan if she requires any further details on the work that HIS is doing to provide additional assurance.
That concludes the urgent question.
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