Tune in TODAY at 9:30am for the first evidence session of our inquiry into the safety of maternity services in England.

: @CfSaferBirths, Dr Bill Kirkup, @CareQualityComm @TeamCMidO and @NHSEngland

Watch here: https://www.parliamentlive.tv/Event/Index/2fefe9f9-fac9-477d-ba07-3222e384f9a5

Follow this thread for live tweets

Michelle @CfSaferBirths gives her brave and powerful reflections on losing her son, Louie, and on trying to get answers. She tells us how the hospital's investigation found multiple failings, but it took four and a half years before the hospital admitted fault in Louie's death.

Michelle @CfSaferBirths tells the Committee that the hospital where her son died still has not apologised to her. She asks - if a hospital cannot accept that things have gone wrong, how can they learn? #HSCmaternitysafety

Michelle @CfSaferBirths calls for independent investigations of baby deaths and for full-term still births in labour to be reported to the coroner to publish prevention of future death reports. She also calls for more staff on wards and better team working #HSCmaternitysafety

Michelle Hemmington @CfSaferBirths asks those working to improving maternity safety to remember that parents have been there since the start and to take parents experience into account #HSCmaternitysafety

A lot of work has gone into improving safety in maternity services, but there is still a lot we don't understand, says Bill Kirkup. The work being led by @TeamCMidO and @matthewcjolly at NHS England is very good but isn't getting to the places that need it #HSCmaternitysafety

@CareQualityComm found a spectrum of quality across maternity units, says Ted Baker. In a minority, there are problems of poor leadership, dysfunction and culture, with doctors and midwives not working together well. But it is more prevalent than first thought #HSCmaternitysafety

Improvements are not happening as rapidly in maternity as in other services, says Ted Baker. 38% of maternity units are rated as 'requires improvement' for safety by @CareQualityComm - this is higher than other specialties #HSCmaternitysafety

Morecambe Bay report is key, says Ted Baker. It talks about defensive culture, dysfunctional teams, poor investigations, poor risk management, safety lessons not learnt: these are still being found by @CareQualityComm - five years on we still haven't learnt all the lessons

Ted Baker says maternity safety is a challenge for the whole system - we all need to work together to drive the cultural change needed. He says if people think we aren't making any progress it's a challenge to keep raising the problem until it's been solved #HSCmaternitysafety

Asked about safety culture among clinicians, Bill Kirkup says he wishes someone had sat him down when he was about to qualify and said, "You will make mistakes, people will be harmed and you'll feel terrible - but you have to be open and to learn from them" #HSCmaternitysafety

Ted Baker agrees, saying that clinicians have to accept their own and others' fallibility - the professional response to mistakes must be to investigate thoroughly, openly and honestly and learn from that to prevent similar mistakes being made #HSCmaternitysafety

Ted Baker says staff recruitment and retention is key to maternity safety - there are locations where it's very difficult to recruit staff - that can be a serious factor in standards slipping. @CommonsHealth will be exploring this more widely in our #HSCCWorkforceBurnout inquiry

Asked about differences in outcomes for Black and Asian mothers, Professor Baker says we need to do more to understand the data - but he is frustrated by hospitals sometimes trying to blame poor outcomes on demographics, rather than trying to address issues #HSCmaternitysafety

Asked about training, Bill Kirkup says it was disappointing that funding for multidisciplinary maternity safety training was withdrawn after a year - evidence showed the training was effective. It would have had a net negative cost in terms of litigation and human loss avoided

There is a role for everyone in addressing blame culture, says Ted Baker. We are all part of the solution as well as part of the problem #HSCmaternitysafety

Asked about possible over-emphasis on 'normal' births, Bill Kirkup says there is a too simplistic framing that we can either have lots of interventions and it'll be safe, or a 'normal' birth that is less safe. He says we can lots of appropriate 'normal' births and a safe service

Ted Baker agrees, saying women should be given choices based on their individual needs, not being told you have to do it this way or that way. 1 in 6 women in labour raise concerns about their safety during labour with their clinicians but feel that these are not taken seriously

Professor Ted Baker says women are equal partners in safety, not receivers of safety. They help drive their own safety & the safety of services. The sense of normality versus intervention is nonsense: women must have what is right for them in the circumstances #HSCmaternitysafety

We are now moving on to question @TeamCMidO and @matthewcjolly about the work they are leading at @NHSEngland to halve neonatal deaths, still births, maternal deaths and brain injury by 2025 #HSCmaternitysafety

We are working really hard to achieve ambitions says @TeamCMidO - for example in stillbirths there has been a 21% fall in the stillborn rate between 2010 and 2018. The 2020 ambition has been met ahead of schedule. But we still have a long way to go #HSCmaternitysafety

@matthewcjolly thanks Michelle @CfSaferBirths for her bravery sharing her and Louie's story, and particularly for her campaigning - getting the messages out is making a difference, he says. Interventions are being made to stop the same things happening again #HSCmaternitysafety

Asked about people feeling shut out from the system after they are affected by a tragedy - which Michelle @CfSaferBirths described - @matthewcjolly says new investigations - both independent and internal - are improving objectivity and can be trusted #HSCmaternitysafety

To achieve equity for the women we care for we need to go the extra mile for the most vulnerable, says @matthewcjolly - for example through the Saving Babies' Lives care bundle which seeks to identify people at greatest risk to target best quality care #HSCmaternitysafety

@TeamCMidO acknowledges concerns around the term 'normal birth' but says in engaging with diverse groups of women she has heard different views including those who don't understand 'unassisted birth' - she says the challenge is what surrounds the concept of 'normal birth'

@TeamCMidO says we need to recognise safety concerns earlier before it escalates into a CQC 'requires improvement' rating. The maternity safety support programme helped 9 trusts in its first year, with 12 trusts currently on the programme #HSCmaternitysafety

Asked about maternity services during the pandemic, @matthewcjolly says he knows how important it is for women to have partners or loved ones with them during key events, but it's been a difficult balancing act to maintain services and maintain safety #HSCmaternitysafety

@TeamCMidO highlights data which shows pregnant women who are Asian are 4 times more likely to be admitted to hospital with covid, with Black women 8 times more likely. There is a 4-point plan which they are working with services to deliver to increase support for at-risk women

@TeamCMidO says research is being funded to better understand the reasons why Black and Asian women and babies are more at risk of dying and we hope that the results of this will be published before Christmas. We are asking services to deliver care proportionate to women's risk

Chair @Jeremy_Hunt thanks Michelle @CfSaferBirths for her important testimony, as well as Dr Bill Kirkup, Professor Ted Baker, @matthewcjolly & @TeamCMidO for their evidence.

You can watch the session here: https://www.parliamentlive.tv/Event/Index/2fefe9f9-fac9-477d-ba07-3222e384f9a5

Join the discussion using #HSCmaternitysafety