My Lords, I start by echoing the very thoughtful words of the noble Baroness, Lady Thornton, and the noble Lord, Lord Scriven, in their reflections on this harrowing report. It does make desperately awful reading. Any noble Lord who took the time to read the report would surely be enormously moved, not just by the story of the cultural and practical problems at the Shrewsbury and Telford Hospital NHS Trust, but also by the personal testimony of Rhiannon Davies—who fought an 11-year campaign after the death of her daughter, Kate—and of Kayleigh Griffiths. They both campaigned stubbornly and with great determination after the deaths of their daughters. They have done a phenomenal thing in bringing this situation to light, and we owe them our compassion and our thanks for their hard work and determination.
We also owe great thanks to Donna Ockenden, who has done a memorable job in terms of this report. It is a massive enterprise that is the result of a huge human investment of time and emotional commitment by Donna and her staff. The report itself is not only huge in scale but great in the humanity with which it deals with this difficult subject. We give great thanks for that.
I reassure both the noble Lord, Lord Scriven, and the noble Baroness, Lady Thornton, that we absolutely take this report seriously. It does outline major issues in the culture of many maternity wards. That is a cultural challenge that is both recognised by the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists, and something that they are working on very well indeed. But I accept that more can be done. In its application, the Government commit not only to implementing the recommendations at trust level but to ensuring that the message made very clearly in the Ockenden report is heard throughout the NHS system.
We are committed to a major investment in the education around midwifery, which includes the rewriting of curriculums, and the Better Births programme, which has already delivered enormous value. There will be a maternity programme review that will update the Better Births programme. There has also been a £9.4 million investment in maternity safety pilots, some of which will be focused on training and some of which will be on safety measures—exactly the kinds of measures that are alluded to in the report.
But the most challenging and, I think, moving element of the report is the stories of the parents themselves and how they were not listened to. This echoes the findings of the report by the noble Baroness, Lady Cumberlege, which, I think, has moved everyone in the House. Time and again we hear the same story, of how those who have witnessed wrong practices and poor culture in the NHS have had to fight the establishment so hard in order to have their voices heard. If any noble Lords heard Rhiannon Davies speak about her own experiences campaigning on this, who would not be moved by that?
We take on board very seriously the recommendations of the noble Baroness, Lady Cumberlege, for a patient safety commissioner. We acknowledge her amendment
to the Medicines and Medical Devices Bill, and we look forward to the Report stage of that Bill in the new year.
I would also like to remind noble Lords that all maternity major incidents—certainly neonatal deaths, stillbirths and brain injuries—are now routinely referred to the Healthcare Safety Investigation Branch, which does an independent investigation. This is an important development since many of the incidents reported by the Shrewsbury and Telford Hospital NHS Trust report. HSIB is doing extremely important work, and I believe that this will be a very large improvement.
Both the noble Lord, Lord Scriven, and the noble Baroness, Lady Thornton, raised leadership. I reassure them both that we have put in place much stronger surveillance, both by the regulators—the CQC and others—and by NHS England to keep track of these sorts of incidents, so that we can much more quickly identify weak spots in the area.
On the question of staffing levels brought up by both noble Lords, I reassure them that the recruitment of midwives—3,000 were committed to in 2018—is going apace. We have committed to a major investment in marketing in order to ensure that we hit our targets on that.
The noble Lord, Lord Scriven, asked whether we were committed to change, or whether this report will sit on the shelf and gather dust. I reassure the noble Lord, and all noble Lords, that we are still very much committed to the maternity ambition to halve stillbirths, deaths and injuries between 2010 and 2025. We are already nearly half way there on that ambition, and we will work relentlessly to ensure that it is achieved.