My noble friend is, as ever, very wise on this. A key plank of the maternity safety strategy, launched in 2016, is a number of initiatives to improve not only clinical care but culture in maternity services. They have been designed to improve leadership and to ensure that in every trust there is a midwife, an obstetrician and a board-level maternity safety champion to spearhead improvement. It is critical that we ensure that this is delivered so that incidents such as this do not occur.