I thank the Member for her comments and questions, and, of course, I'm sorry for any family who suffers the loss of a baby or a young child. I would not want any family to feel the way that you described. Now, I can't, obviously, comment on the individual circumstances, but I do want to be clear that part of the point of this review is to try to learn what has happened. We're now looking at 44 cases in that cluster of cases to be reviewed. It's not clear at this point that care has gone wrong in any or all of those cases, but the cluster of cases of concern is why there is an imperative to investigate, and hence the now independent review with the two royal colleges, with oversight from the chief nurse and the chief medical officer.

The health board do, of course, now have that additional scrutiny that I've outlined in my statement—additional scrutiny and support to look at both clinical practice, clinical culture, but also one of the points you made—clinical leadership. In fact, we're having the review now because a new head of midwifery services saw some of the data and flagged it up as a concern, and that's led to the issue being escalated. But part of our challenge is to make sure that it doesn't need to have an additional fresh set of eyes at that level.

So, there are good reasons to have the review and to want to learn from it, but I'd be cautious about saying that in every single instance there has been a failure of care. That's why we have the review—to look at those individual circumstances, to understand what is individual, what is cultural, what does it tell us about practice, and to help us to make recommendations for the future as well.

Now, I've been clear in my statement on publication so the recommendations and any response to those recommendations from the review will be published. What I can't tell you is that there is a timetable. It's regularly the case that, for politicians, you would want to set a timetable that is prompt or long, depending on your perspective. I think it's important the colleges have the terms of reference to allow them to do what they need to do in a properly independent and robust manner, and I don't set an artificial timetable, but, obviously, I'd want the review to be as prompt as possible. The sooner we have something that is robust and understood, then the sooner we're able to understand what measures do or do not need to take place, and also what is individual about the health board and what is system-wide learning, and what is a system-wide challenge across Wales.

On your point about centralisation, these services have not yet been centralised, and so the model itself, a new model, isn't a contributory factor. We're looking at practice, but there are arguments that I'm sure the colleges will want to look at in terms of the optimal organisation of the service, and we know that in the past, though, our royal colleges said that the move that we're making is towards a better model to provide better care. Well, they're matters that I'm sure will be commented on in the review, and, as I say, that will be published together with any response to it.