I thank the Member for his question. As I indicated earlier, one instance of this sort of care and challenges in care that lead to undignified endings for individuals in Wales is one instance too many. We already have a range of actions in place. There’s been a mortality review of different case notes. We’re the first nation within the UK to undertake that approach. That is all about learning from what happened. That’s the whole point—how we learn from what happens and how we try to improve. Now, I regularly get asked questions in this place and others about what the NHS does, and I think it’s really important not to either try to claim that everything is wrong where something does go wrong. We know that when things go wrong in the health service it has a significant impact on individuals and their families. I don’t try to hide from that or that reality, but the great majority of the time, it does not go wrong. I don’t want to see these really tragic cases used to try and attack the whole health service, to try to give the impression that everything is wrong. What we need to do is understand the nature of our challenge and properly address it.

In fact, what we did was we got together the 1000 Lives Improvement programme—representatives from the medical world, nursing, ambulance and the chair of the rapid response for acute illness group to come together to design this specific peer review process to make sure that we are addressing the concerns set out by the ombudsman in his thematic report. We then can have some proper learning with real scrutiny in public—the report will be published and made available—and the improvement actions, importantly, to come from that. Always, we need to look at what we can do to improve our whole system to make sure that if you or I or one of our loved ones were in this position, we could have some reassurances it would not be the case, and we’d certainly minimise and level down the opportunity for it. We’re constantly looking for opportunities to learn and to improve.