Thank you, Presiding Officer. First of all, I would like to put on record how incredibly sorry I am for the affected families. A moment of maximum joy is what they should have been feeling, but it turned to events of terrible despair, and we are appalled by what's happened. 

In July of this year, a young couple came to see me. It's an appalling situation. They are part and parcel of what's happened here: a consultant who didn't visit the mother's bedside because of his rage at being put on a rota he wasn't expecting; warning signs that were ignored; a baby, barely alive, who was moved to another hospital and put on a cold cot, but to no avail. Having read their horror story, what really struck me, Cabinet Secretary, was the health board's reaction. They wrote to the chief executive officer saying what had happened and asking for help to understand it and for more information. They were essentially palmed off to a junior staffer who was reluctant to engage. There seemed to be a total lack of compassion for people at their lowest ebb, a dismissive attitude, a dragging of heels, no apology of any meaning—and I'm not talking about financial, I'm talking about the sincerity level. There was no timely response to letters.

So, how will you, Cabinet Secretary, ensure that the health board provides proper support to these families who've been affected? In your statement, you say that you expect them to provide support for the families, but I can tell you that, from the evidence that I saw, the reports that were written and the letters that were sent to this young couple, that did not happen. So, I'd really like to understand in what meaningful way you can ensure that this health board do what they should do, and actually come alongside these families. 

Of course, at the time, I didn't realise that this seemed to be part of some kind of systemic failure. So, Cabinet Secretary, the independent review that you are going to put in—will they be going through each case themselves, because in your written statement you say that some have now been reported and are being fully investigated? Again, from the paperwork that I was given by this young couple, within Cwm Taf health board, an independent paediatrician actually wrote a report that was pretty scathing about what happened to them, and it was ignored by the health board. So, will you be able to get your independent review, or ask the independent review, in their remit, to really dig down into the individual cases to ensure that there is no possible forgetfulness of the events or an abrogation of transparency, because I think it is the least that these families deserve? And do you have a timetable for when you would hope to have this review report back? 

And, of course, you'll know that throughout Wales, at the moment, we're going through quite a significant transformation agenda; there's a lot of centralisation going forward in other health boards at present. So, how will you ensure that lessons learnt from the Cwm Taf experience are actually translated really well into all those other health boards, because I think that we need to put these health boards on notice that if we're going to do this stuff, we have to do it safely and we have to remember that the patient is what it's all about, and that these mothers and babies—wherever they are in Wales—deserve the chance to have a successful outcome?  

Cabinet Secretary, I was also really concerned that this trend didn't seem to be spotted earlier. So, will your independent review be looking at that? Will they be looking to see whether or not the agencies that are responsible for monitoring performance and outcomes within health boards—where were they? Why didn't they spot it earlier? Did anybody step in to say, 'Hang on, something here doesn't look right,' because we've got access to mortality figures? We should know what should be the right trend and what shouldn't be the right trend.

I will say that my young couple are now in the safe hands of an Assembly Member on another bench to mine, because that individual is actually their constituency Assembly Member, but I just want to say that, of all of these families who have been affected by this, if their stories are anything like the young couple who came to see me with their sheaf of paperwork, and told me of the fear that they have of trying to have another baby, having lost their little girl at six days through a catalogue of errors that was nothing to do with them, then we should be absolutely determined to make sure that Cwm Taf are held to account, the right people are held to account, whoever they may be, and that we learn these lessons in a meaningful way. There's a very big health board in England that's going through a not dissimilar process at the moment. We should be learning from each other. This shouldn't happen. It is a real tragedy.