 The next item of business is a statement by Shona Robison on NHS Sears of Ayrshire and Arran maternity services healthcare improvements Scotland review of adverse events. The cabinet secretary will take questions at the end of her statement so there should be no interventions or interruptions. I call on Shona Robison, cabinet secretary. Ten minutes please. Thank you, Deputy Presiding Officer, for giving me the opportunity to make this statement. I will also be aware that in December 2016 I asked Health Improvement Scotland to undertake an independent review of the management of adverse events within Ayrshire maternity unit at University Hospital Crosshouse and that this was commissioned in response to concerns raised by families about the management of adverse events in the unit. Let me begin by extending my heartfelt condolences and sympathy to the families involved within the review sentiments that I am sure everyone in this chamber shares. NHS Ayrshire and Arran have already apologised and I want to extend my personal and sincere apologies to the families affected. I would also like to take this opportunity to thank the many members here today who have made representations on behalf of constituents and who took a keen interest in the review and its outcome. This review followed two previous relevant reviews into the management of adverse events in NHS Ayrshire and Arran carried out by his in 2012 and 2013. To ensure that we heard from all the families who wanted to share their stories, I sought assurance from his that no families would be excluded and that their views and experiences would be reflected in the final report. Sixteen families in total were involved in contributing to his review and his have shared their findings of the review with the seven families who wanted feedback, which has delayed the publication slightly. The report makes eight recommendations for improvement. Six for NHS Ayrshire and Arran focused on changes to the adverse event review process to ensure that it meets the national framework and provides simple, useful and practical processes. Improved family engagement and communication to ensure that families are provided with the right information, support and opportunities to be involved in a significant adverse event process. Improved support for staff, including dedicated time to be involved in all aspects of adverse event reviews, included protected training time. Promotion of shared learning internally and externally from their improvement work, including publication of learning summaries of adverse event reviews, revised procedures for publication of reports so that they preserve patient and family confidentiality and, at the same time, encourage shared learning and improved identification of and access to training for staff, including producing a training needs analysis and ensuring access to training programmes. One recommendation is directed to his to ensure that the findings of the review support the further development of the national framework for adverse events and the quality of care review approach. One recommendation is for NHS Scotland to develop and agree a list of mandatory skills and competencies for maternity services. In parallel with his review, NHS Ayrshire and Arran commissioned an independent team of experts from the University of Leicester to review the clinical care in recent cases of stillbirth and neonatal death in the maternity unit. The team examined several cases and concluded that it is possible that differences in care may have led to different outcomes for some of those babies. The report recommendations focus on quality of care staffing and improvement activity in the unit. I also want to highlight to Parliament two other reports that were published last week that look at stillbirth and neonatal death. On 21 June, the Royal College of Obstetricians and Gynaecologists published a report into the findings of their each baby counts programme. The report made expert recommendations for improvements to the quality of care for mothers and babies to reduce stillbirth and early neonatal death. On 22 June, Embrace published their perinatal surveillance report that provides an indication of the relative rates of stillbirth and neonatal deaths across the UK in 2015 and shows that Scotland has the lowest stillbirth and neonatal death rates anywhere in the UK. Those reports are important because they highlight incidents across Scotland but also because they show where general improvements can be made to services and that fewer families are experiencing their loss every year is something that we should welcome. Turning back to the His and University of Leicester reviews, I have spoken today to the vice chair of NHS Ayrshire and Arran and I have made it very clear to the board that I view the substandard practices uncovered in the reports as unacceptable. NHS Ayrshire and Arran has apologised to families and offered to meet and discuss their cases with them in person. The board has contacted families directly or are working with the stillbirth charity SANS to contact other families. SANS will also offer their full bereavement support to any of the families who want it. The board has also today published a set of action plans to implement the recommendations. That includes plans to appoint a risk and quality improvement team for maternity services, comprising senior maternity staff to support the changes that are required in the action plans. The board has also invested £1 million in midwifery staffing since 2014 and, in addition, has appointed an additional consultant obstetrician and clinical risk midwife. I welcome the response from NHS Ayrshire and Arran and have been clear with the vice chair that expects those plans to be implemented and evidence of the improvements published. I will meet the board soon to get an update on implementation and I am happy to report back to Parliament on progress. His will monitor progress against the implementation of the recommendations every three months in the first instance. That information will be fed into the wider quality of care review assessment for this board. Quality of care reviews of NHS boards will commence in the autumn and those will include a focus on the leadership and governance issues that are surfaced by his review. The whole Scotland issues will also be fed into performance reviews with NHS boards across the country. We will work in partnership with health boards to agree a core mandatory update training programme for maternity staff before the end of the year. It is very important that we reassure people, particularly expectant mothers, about the overall safety of our maternity services. Our rates of stillbirth and neonatal death continue to decline and, according to the Embrace report, in 2015 we had a record low rate for Scotland and approaching the rates of the best-performing Scandinavian countries. NHS Ayrshire and Arran has seen a 50% reduction in its stillbirth rate over the past three years as a result of the improvement activity already undertaken. In the light of the Kirkup report into services in Morecom Bay, we instigated our review of maternity and neonatal services in Scotland. The best start report that was published earlier this year and implementation of the 76 recommendations is under way and will deliver safer and higher quality maternity care for women and babies. I also want to highlight a range of other activities that are focused on learning from adverse events and continuous improvement, including the Scottish patient safety programme, in particular the MCQIC programme, which aims to improve safety in maternity, neonatal and pediatric services, greater consistency and improved quality of adverse events investigation and reporting through the adverse events framework. The duty of candor provisions, which will come into effect on 1 April 2018, the Apology Scotland Act 2016, a revised NHS complaints procedure and the ability for individuals to raise concerns independently through care opinion. In addition, I have asked my officials to prioritise a programme of work to support more effective learning systems within NHS services that support people affected by adverse events, conduct rigorous reviews and to share findings. This work will be overseen by the CMO and the national clinical director. I have also written to all health boards drawing attention to the findings and asking those boards with above-average rates of stillbirth and neonatal death to undertake independent reviews of the quality of care and then report back on plans for improvement. Later this year, our standardised perinatal mortality review tool will be launched, which will ensure that all cases of stillbirth and neonatal death are systematically investigated and that parents and families are fully engaged in that process to ensure that they get the answers that they need as quickly as possible. Finally, I want to return to the people who matter most. That is the families who have been part of the review and have bravely shared their experiences with me and some of my colleagues here in the chamber. It was thanks to them that the investigation took place and that the resulting improvements to care has happened and will happen. I want to thank them for the dignity and determination that they have shown. I have offered to meet all those families whose cases were included in the report to discuss the findings and listen further to their views. Those meetings will be arranged over the next few weeks. However, in recognition of the role that they have played in raising awareness, I would also like to offer them the opportunity to be involved in the oversight of improvements. I will establish an oversight group comprising families and representative organisations to take forward scrutiny from the service user's perspective of changes that are happening, not only in Ayrshire and Arn but in maternity and neonatal services across Scotland. I have written to all boards making it clear that I expect them to be open and proactive in their communication with families who want to discuss any concerns about their care and I would encourage any family who may have unanswered questions relating to their maternity care to contact their local board. I give my personal commitment to the Ayrshire families that action will be taken in the light of those findings. I have already expressed my sympathies and I apologise to the families but I also want to record my thanks to them and I am hoping to do that in person when I meet them. I am sure that the chamber will also want to join with me in expressing our gratitude. I am happy to take questions. Thank you, cabinet secretary. The cabinet secretary will now take questions on the issues raised in her statement. I intend to allow around 20 minutes for questions after which we move on to the next item of business. It will be helpful if those members who wish to ask a question repress their request to speak buttons now. I call first name Brian Whittle to be followed by Anas Sarwar. Mr Whittle, please. Thank you, deputy secretary. I thank the cabinet secretary for early sight or for statement. I also declare an interest in that my daughter is a healthcare professional in the NHS. Apart from the fact that his have had their wings well and truly clipped and a very narrow instruction from the cabinet secretary on what they were permitted to investigate, the report throws up some very glaring issues. Red flags that should have been noted have been flying for the best part of a decade, deputy Presiding Officer. From 2009 to 2012, there were 57 adverse event reviews in Ayrshire and Arran. Following a his review instigated by the then health secretary, Nicola Sturgeon, that number fell to zero in 2013, only one in 2014 and seven in 2015. That is a significant key indicator that should have thrown up a massive red flag and at least been investigated. When I asked his directly about the implications of those numbers, he answered that they do not routinely monitor those numbers. The his report then states, and I quote, that the NHS Ayrshire and Arran significant event review process was not used for significant events in the maternity unit. Given that his categorically stated that it is not their responsibility, can I ask the cabinet secretary who is responsible for monitoring the implementation of recommendations from his review? How will that be measured? And how can the families affected by those tragedies and the NHS staff themselves possibly have any faith that this review, subsequent to 2012 and 2013 reviews, will change anything? First of all, can I thank Brian Whittle for his questions, but also for his long-term interest in the issue? It has been important that members within the place have raised issues on behalf of constituents. That has helped to ensure that the reviews have shed a light on many aspects of the practices that have not been acceptable within Ayrshire and Arran. Can I say to Brian Whittle that he acknowledged in his question that his report is very thorough and that it goes beyond the issue of just looking at the significant adverse event review process, although it deals with that in some detail. It looks at things such as communication with the families and the way that boards should engage with families when something goes wrong. It goes beyond and gets into those very important issues. As I laid out in my statement, he will be monitoring the implementation of the recommendations within Ayrshire and Arran on a three-monthly basis. I will be taking a very close personal interest in that as well. I will be meeting with the board to get my personal reassurance of the implementation of those recommendations. The board has established mechanisms and oversight to ensure that it is at the most senior level within the board that that oversight is provided. We should recognise that Ayrshire and Arran have already taken many of the steps to improve the services and that the external verification of the quality of services within Ayrshire and Arran shows a very different picture than before. I hope that Brian Whittle will take some comfort from that. I am also happy to keep him and other members very closely in contact with that progress as we take it forward. I thank the cabinet secretary for prior sight of the statement and joining with her in sending our heartfelt condolences to all the individuals and families affected by the tragedy. Although the report covers Ayrshire and Arran, clearly there is a wider issue with adverse events having taken place in other maternity units in Scotland too. There are believed to be between two and three preventable deaths of babies in Scotland each week. While I welcome the recommendations on how to deal with adverse effects, it is unfortunate that the report did not investigate the quality of care and give recommendations on how to prevent adverse effects. The report, the Biskotten report and indeed the maternity and neonatal review all point towards a workforce crisis with understaff wards, high vacancy rates and high use of agency staff, which is having an impact on patient care and safety. I therefore ask the cabinet secretary, in light of the fact that the review is now under way in terms of the recommendations being implemented, when the reduction in neonatal intensive care units will commence and when that will be completed and whether she is giving consideration, particularly considering the families at the heart of the situation, if she is giving consideration to implement independent public inquiry that will give confidence to the families and lastly when she herself will come back to Parliament and give us an update on how the review is being implemented and what recommendations have been taken forward so far. On the last point, I will be happy to give regular reviews back to Parliament on local implementation with a nation arm and on the wider changes that are being made. The point that Annasarwar, the question that Annasarwar made about the prevention of adverse events is a really important one. I think that those reviews are very important and the actions that they set out and the implementation of those changes will make sure that our services are as safe as they can be. Sometimes, as we know, events happen within our NHS and those are very difficult to predict and sometimes those are unavoidable. However, what we are talking about here is trying to prevent avoidable adverse events happening. One of the key elements within the recommendations is, for example, the CTG training, which is around fetal heart rate monitoring. That will be mandatory and the chief medical officer is going to ensure through medical directors that the training is mandatory. That is really important. It is also something that Mr Morton raised directly as being a key weakness, as he said, in his very sad case of the death of his son, Lucas. I want to say to Mr Morton that I hope that that gives him some personal reassurance that that very important issue about the training of our midwives in interpreting CTG will be a very important thing. It will have to attend a minimum of two sessions per annum. It will be mandatory, and the CMO will give oversight to that. In terms of the public inquiry, we have now had a number of inquiries and reviews. His review and indeed the Lester review have identified a number of issues that now have to be resolved. Many of those important changes and improvements have already been made. Those recommendations lay out what more has to be made. I think that the most important thing is that we get on with doing that. I believe that the actions that are already taken and those that will be taken will give us the best chance of avoiding future unnecessary and avoidable deaths within our units. I have 10 members wishing to ask questions. I am asking you to be disciplined and go straight to questions to allow all members in on this very important and sensitive issue. I call Willie Coffey, followed by Jamie Greene. I have just received the report and spoken to the chief medical officer. It is clear that Ayrshire and Arran had not fully implemented the recommendations that were made to them in 2012-13 with respect to training for staff and openness and transparency and how they supported affected families. What action does the cabinet secretary propose to take on this to improve safety, ensure and verify that any new recommendations are carried out? How can Ayrshire and Arran regain the trust of all families who are affected by these tragic events? I recognise the fact that Willie Coffey has raised cases with me directly. I am glad that he met the chief medical officer earlier on, as Brian Whittle did, because he was able to go through some of the detail on what is a very complex set of complex issues and complex reports going into quite some detail. The point that Willie Coffey makes is a simple one. How can we be assured that the recommendations that will make a difference and, importantly, will make our services safer? How can we be assured that those will happen? First of all, I will make sure that the oversight that the Scottish Government provides through the chief medical officer and through our clinical director, that we keep a very close eye, not just on Ayrshire and Arran's implementation, but on the rest of our board's implementation. As I said in my statement, I have written to boards sitting out my expectations of doing that. The mandatory training will be monitored to make sure that midwives are getting the opportunity to have that critical training. Of course, we would expect healthcare improvement Scotland, as it is doing with Ayrshire and Arran, to take a very close three-monthly update of how those recommendations are being implemented. I hope that all that is taken together will give Willie Coffey and, importantly, the families reassurance that those recommendations will be taken forward. Of course, it is important to recognise the improvements that have already been made within Ayrshire and Arran, including the 50 per cent reduction in the rate of stillbirth since 2013. I think that that should be acknowledged. There was a history review in 2012 and another in 2013. Today, we review the recommendations of another in 2017, with an unfortunate sense of deja vu and some of the points that it makes. As Brian Whittle points out, his is not a regulatory body nor has the power to directly instruct health boards to comply with the conclusions. I can ask the cabinet secretary what measures are available to her if health boards do not comply with the recommendations of those various reports. Ultimately, I have ministerial powers of direction over health boards, but I hope that the measures that I have set out will be taken forward by health boards over their own accord. At the end of the day, they should be motivated, and I am sure that they will be motivated, to want to provide the best possible and safest services to babies and their mums. Can I say about Health Care Improvement Scotland? It is important to note that, when Health Care Improvement Scotland undertakes an independent review, it brings in people from outside. For example, in this case, the review was chaired by Tracy Johnson, who is a consultant obstetrician at Birmingham Women's Hospital, bringing in the external independent view of the service. I think that it is fair to say that it has very much shone a light on areas of practice that need to improve. I should also say that Health Care Improvement Scotland has also got extensive powers. It has the same independent legal status, for example, as the Care Quality Commission in England. The minister has a point in the same way north and south of the border. It has powers of intervention. It can close wards, for example. It does have extensive powers, as do I, but I would hope that we will see boards getting on with implementing those changes, and we will certainly give a strong and close oversight to make sure that that happens. Kenneth Gibson, followed by Colin Smyth. The health service of NHS Ayrshire and Arn over three years has very welcome progress. Nevertheless, does the cabinet secretary accept that many brief parents in Ayrshire feel that some of their questions remain unanswered or have been answered only after intensive lobbying by MSPs, patient groups and others on their behalf? Will all of the recommendations be implemented by other health boards? What further steps will be taken to absolutely minimise the number of stillbirths and neonatal deaths, not just in NHS Ayrshire and Arn, but across Scotland? To Kenneth Gibson, I recognise how much of an interest he has taken in those issues and continues to do so. He makes some very important points about the bereaved families and their questions of which they may feel that they still have questions that remain unanswered. I will be meeting, as I said, with the families who want to meet me, and we will talk about whether they feel that there are still questions that are unanswered. We will look at how we can ensure that they get answers to any remaining questions that they have. In terms of other health boards, we would expect all health boards to implement those recommendations. Of course, the focus has been on Ayrshire and Arn for understandable reasons, but we would expect all health boards to equally implement those recommendations. In terms of external assurance, Kenneth Gibson will hopefully be aware that embrace was established as a UK surveillance team to make sure that every year they can shine a light on those units that are above the average for stillbirth and neonatal deaths. That is very important. Through that, we have seen that, in 2015, Scotland's units have been performing very well indeed. We have seen the lowest rates of stillbirth and neonatal deaths across the UK in Scotland, but we are absolutely not complacent. There is more work to be done to ensure that that improvement continues, and I am determined to make sure that that happens. Colin Smythfall, Emma Harper. Cabinet Secretary, the review praises maternity staff at Crosshouse hospital for their professionalism but highlights the impact of staff shortages, revealing that, in March 2017, a senior manager in Ayrshire and Arn said that staff shortages were and I quote, contributing to her ability to deal effectively with day-to-day workload and provide effective and safe care for women, children and neonate. They went on to say that staff could not be released for training and, therefore, I quote again, will not be trained to the standard to provide assurances of the quality of care being delivered. Will Ayrshire and Arn have now increased staffing, can the cabinet secretary give a personal assurance to families across Scotland that all our maternity units are currently adequately staffed and that those staff have the training that they need? All units apply the workload planning tool and, as part of the work that is going forward, we will be wanting to make sure that all units are doing that. Of course, the member is quite right and, in his question, pointed to the staffing increase that there has been within the Ayrshire maternity unit. Quite significantly, we have seen a rise in the whole-time equivalent from 2014-15 from 181.34 to 2016-17 of 196.77. Since April 2016, additional funding for 6.6 whole-time equivalent midwives has agreed, and at the end of June 2017, an additional 14 whole-time equivalent midwives are currently in the process of being recruited. That is because of the application of the midwifery workload planning tool. We would expect that planning tool to be applied to all units to make sure that not just the numbers of staff but that the staff reflect the needs of the patient cohort and can be adjusted depending on the needs of the patients within the unit. Emma Harper will talk about Alison Johnstone. I remind members that I have a licence to practice as a registered nurse. What financial support will be provided to help NHS Ayrshire and Arran to implement the recommendations that are outlined in the report? First, we should recognise that Ayrshire and Arran have invested more than £1 million in additional staffing, particularly in expanding their midwifery workforce. Of any additional resources, we are making sure that we support Ayrshire and Arran through resources from the Scottish Government in terms of people and expertise. Healthcare Improvement Scotland will be doing likewise. Ayrshire and Arran have set up an established oversight team, which they have resourced to ensure that they can have confidence that those recommendations are taken forward. We will continue to speak to Ayrshire and Arran about any other support that they may require. I am glad that the cabinet secretary has highlighted the valuable role that sands play. I would appreciate if the cabinet secretary could inform us of how the Scottish Government is drawing on its expertise to improve support for bereaved parents. There has been some discussion of a national bereavement strategy. Can the cabinet secretary offer any updates on that strategy, and how it might reflect the psychological and emotional support that parents need in those most devastating circumstances? I thank Alison Johnstone for her question. I thank sands for the support that they have provided and have offered to provide to families and will continue to provide in any further meetings that families want to undertake with the board and indeed with myself and others. They provide a very, very important service. In terms of the national bereavement strategy, work is on-going with that. I am happy to write to Alison Johnstone to update her on that. It is very important that families that want that support, not all will, but any families that want that support, are offered it as quickly as possible. Does the cabinet secretary recognise that the emotional support referred to by Alison Johnstone available to families affected by Sylverth is not universally available across Scotland? In that context, what additional support will her Government extend to charities like sands, and what will she do to extend NHS support to those families dealing with the long-term emotional trauma of adverse events living in health boards not currently served by specialist perinatal mental health teams? We would expect boards to make sure that families get the support that they require, no matter where in Scotland they are living. Sands is a key organisation providing that support, and we will have an on-going dialogue with Sands about how we make sure that they are supported in order to continue doing that work. We will make sure that families who will perhaps still come forward that, first of all, the boards listen to what they have to say. There is an open culture of hearing and listening and acting on concerns that are raised by families. We have, of course, the changes that are coming forward in relation to the legislation to require boards to have a more open and transparent culture in relation to the duty of Canada. I think that that will help to make sure that we have the right culture in order to ensure that people can come forward, but, importantly, when they do, they get the support that they need. I apologise to the three members. Clare Haughton, Donald Cameron and Fulton MacGregor were not called, but I thought in this instance that it was important on this topic to allow longer questions and certainly longer answers. That concludes questions, the cabinet secretary, and we will move on to the next item of business shortly.