Part of 1. Questions to the First Minister – in the Senedd at 1:44 pm on 30 April 2019.
Well, the report that has been published today, Llywydd, is a very difficult read, and something went seriously wrong in Cwm Taf maternity services. What I think the report demonstrates is that failures happened at many levels. They were professional failures. The report undoubtedly demonstrates that there were behaviours by doctors and other clinical staff, sometimes, but not always, because of the pressures that they were working under, that do not stand up to the test of professional conduct, that there was a failure of leadership and that that created a blame culture inside that service that meant that when people felt they had something to say, they were reluctant to say it. It demonstrates that there was a systems failure, so it's not just about individuals—it is about the way the system itself responded to those concerns. And then there was a failure of the organisation itself to see what was going on and then to respond to it properly. So, I don't think it is as simple as being able to point the finger at particular individuals, because the report demonstrates that those failures took place at many levels, and putting those things right will require action right across the board and amongst those people who work for it.