My Lords, as a Secretary of State responsible for the health service for some of this period—two years out of two decades—I share in the responsibility for what happened here and for the fact that it was not known about and that action was not taken sooner. I am sure that others who have been Ministers in the department over these two decades will feel likewise.
What is shocking is not only the individual trauma that parents have suffered but the scale of what the Ockenden review discloses—we are grateful to Donna Ockenden and her colleagues for persisting in trying to understand and disclose the scale of what has happened. I ask my noble friend about our responsibility, which was, of course, that there should be external oversight and action taken when these things go wrong. From my point of view, one of my objectives was that there should be more clinically led commissioning so that local clinicians would understand what was happening and have the power to step in.
The Ockenden report shows that, in May 2013, the clinical commissioning groups set up a review that, in October 2013, reported:
“The overall findings of the review demonstrate that this is a safe and a good quality service”.
I encourage Donna Ockenden and the department to look very carefully at how they could ensure that local clinicians responsible for commissioning take that responsibility seriously and act upon it.