Nobody could fail to be moved by what these parents have gone through. Of course I join him in expressing my enormous sympathy for what has happened to them—of course. All of us, I'm sure, in this Chamber will more than empathise with the situation that they find themselves in, of course.

Well, what should be done as a result? First of all, the ombudsman's report was clear in its findings that the care provided was unacceptable—by more than one hospital, but unacceptable. The health board has accepted the report's recommendations in full. They have sent their action plan to us. Officials will now monitor the actions taken by the health board to ensure that the recommendations within the report are implemented. There has already been a great deal of learning and improvement in practice as a result of what is, of course, a very sad case, and we will ensure that that continues. As part of the learning process, I can say that we expect all NHS organisations to reflect on this case to identify any learning to improve patient care within their own respective organisations as well. So, yes, Hywel Dda will take action. That action will be monitored by us.