Can I put on record at the outset of my remarks my thanks to Donna Ockenden and her team for their work in compiling this very comprehensive report? Unlike the headline in the previous HASCAS report, published in May, this report has been widely welcomed and accepted by stakeholders, and I think that it's very important now that the National Assembly has the opportunity to consider both of these in a full Assembly inquiry at some point in the future. As part of that inquiry, I think we need to look at the effectiveness of the action that's been taken under special measures to date. 

You said in your statement, Cabinet Secretary, that it's another difficult report for the board, and that of course is absolutely the case. The report is a litany of failure, it lists a catalogue of problems at the health board, including governance and management systems that were flawed from the outset; delays in appointing staff to clinically essential posts; staff who describe, in their words, being exhausted, depleted and unheard, working in a dangerous working environment; an estate that isn't fit for purpose, posing a risk to patient safety; and a complaints procedure that isn't working; and an organisation that doesn't learn from its mistakes or implement agreed action plans. 

But of course it's not just a difficult report for the board, it's also a very difficult report for the families of those affected by the failings of care on Tawel Fan. I have to say, many of those families remain absolutely baffled by the overall conclusion of the HASCAS report that was published back in May. Some of them are still waiting for their individual patient reports about their family members. I ask you, Cabinet Secretary, given that you've made very little reference to the families in your statement today: when will they receive those individual patient reports? At what date can they expect some closure on some of these issues?

And of course it's not jut a difficult report for the board and for those Tawel Fan families, it's a very difficult report for you too, or it certainly ought to be, because you've been responsible for the oversight of the special measures arrangements at the Betsi Cadwaladr university health board from the day that those special measures started, in your previous capacity as Deputy Minister for Health and now as Cabinet Secretary. It's very clear from this report, this is not a historic document; this brings things right up to date to the current time. It's very clear that those special measures are not working. You can try to pass the buck back to the health board, as no doubt you've already done today in your statement.

We were told initially that we had 100-day plans to turn the health board around. Well, it didn't even veer one inch to the right or the left in an attempt to turn around, and this report seems to demonstrate that. It's now been more than 1,250 days and I think that lots of people in north Wales have lost confidence in your ability and the ability of your Government to have special measures that mean something and actually deliver the pace and progress of change that we need to see. I know that you say on a regular basis that you've made your expectations clear. I'm fed up, frankly, of that line, and so are people in north Wales. A weekly rant, an e-mail from an ivory tower in Cardiff Bay is not going to deliver the change that we need to see in patient care in north Wales. We need more action not words, apologies not excuses, and accountability not an avoidance of responsibility.

So, I ask you today: will you apologise for the failure of special measures to date? Do you accept some responsibility for the failures outlined in this report? Because some of them have been failures that we've seen on your watch while this board has been in special measures. It was put into special measures, in part, to deliver the outcome of some of the recommendations in the individual investigations and reports that have been undertaken by various bodies. They clearly haven't done that, because the report says that very, very plainly.

People still find it absolutely astonishing that not one person at the health board has been sacked as a result of the failings that have been itemised in this report. Yes, we've seen some changes in the senior leadership team. We've seen some of those executive team members change. But, some of those senior managers are still employed by the board, including some of those who were in a position to be able to change things at the board. One individual, for example, the former chief executive, has recently been appointed as the board's turnaround director. Can you believe that? A turnaround director. You couldn't make these things up. It's a disgrace.

We know that patients have come to harm. Some patients, as well, when you go back through this report, have actually died as a result of the failures in governance and leadership at this board. And, frankly, I think that those responsible should never work in the national health service again—ever—and I think it's your job to determine that there is action taken to deal with that accountability issue. I'd be grateful if you could tell us what you're going to do—