Item 4 is the statement by the Minister for Health and Social Services on Cwm Taf maternity services, and I call on the Minister for Health and Social Services, Vaughan Gething.

Thank you, Deputy Presiding Officer. I have today published the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives report, following their review of maternity services at the former Cwm Taf university health board. This is accompanied by a further report, which provides accounts from the women and families who have used these services. Members will now have had an initial opportunity to consider the reports, and my written statement issued this morning.

I want to start by reiterating my apology to all the women and families affected by the failings and poor care described in the royal colleges' report. There is no doubt that the service provided to many women and their families fell well below the standard that I or anyone else would and should expect from our national health service. I do, though, want to thank the women and their families who shared their experiences to inform the review. I can't begin to fully understand the impact for those who have experienced unsafe or uncaring practice. Like most parents across Wales, our family's experience of maternity services was a positive one—one that every parent has a right to expect. The failings described in the report have no place within our NHS. I'm determined to ensure that this report is a catalyst for immediate and sustained improvement.

I commissioned the independent review of both royal colleges in October last year, after concerns relating to the under-reporting of serious incidents were brought to the attention of the Government. The reviewers have spoken with families and staff, and considered the information provided to them by the health board in forming their conclusions. My officials received the final reports on 16 April. 

The report describes a number of serious concerns and there is a clear call for action. It highlights failings in governance, data accuracy, serious incident reporting, leadership and culture. The review makes clear that this has had an impact on pregnancy outcomes. The accounts from women and their families provide a deeply upsetting insight into how these failings have impacted on their experiences of pregnancy and childbirth. The report also acknowledges the extreme pressure that some of our staff have been working under. There are also significant concerns and questions about the effectiveness of the wider board leadership and governance. 

In my statement this morning, I set out the steps that the Welsh Government is taking, and I'll now take this opportunity to confirm those measures for Assembly Members. As part of this response, I have placed maternity services at the former Cwm Taf university health board into special measures.

It was incredibly distressing for me to read that women and families did not feel that they were taken seriously when voicing their concerns and worries. Whilst within the report there was feedback that reflected individual good practice, overwhelmingly those who contributed spoke about distressing experiences and poor care. This morning, my officials have met with some of the women and their families affected to discuss the report, and to seek their continued engagement to improve the service. It is vital that their voices continue to be heard, and I again want to extend my thanks to them for the courage and resilience they have shown in telling their stories.

The report makes a significant number of recommendations, grouped across 10 main areas in the terms of reference that I set. I fully accept the recommendations of the report and I am grateful to the reviewers for their work. The focus now must be on implementing their recommendations. In order to achieve this progress, I'm taking action across three main areas: maternity services in the former Cwm Taf area; broader governance in Cwm Taf Morgannwg; and finally, seeking assurances on provision across Wales.

Firstly, I'm establishing an independent maternity oversight panel. This panel will be tasked with seeking robust assurance from the health board that the report recommendations are being implemented against agreed milestones. The panel will establish an independent, multidisciplinary clinical review of the 43 pregnancies considered by the report. These were identified in a look-back exercise to January 2016. The panel will also ensure that a look-back exercise to 2010 is undertaken, as recommended by the royal college's review. I want to offer reassurance that women who feel they have had an adverse outcome will be able to have their care reviewed.

The independent panel will also have a role in advising the health board on how to effectively re-engage the public whilst improving maternity services in the former Cwm Taf area in a way that generally does rebuild trust and confidence in the service. Mick Giannasi, the former chair of the Welsh Ambulance Services NHS Trust, also a former commissioner for Anglesey council and a former chief constable of Gwent Police, has agreed to chair the panel. He will be supported by Cath Broderick, the author of the women and families report, who will continue to engage with women and their families. And they will be joined on the panel by senior midwifery and obstetrics leads who are, of course, independent of Cwm Taf. 

Secondly, I am putting in place arrangements to improve the effectiveness of board leadership and governance in the organisation. I've asked David Jenkins, the former chair of Aneurin Bevan University Health Board, to support the chair of Cwm Taf Morgannwg to provide assurance on the implementation of the recommendations. And Mr Jenkins will also advise me of any further action that may be required to improve governance at the board. The NHS Wales Delivery Unit will work with the health board to ensure that there are effective arrangements for the reporting, management and review of patient safety incidents and concerns. Healthcare Inspectorate Wales has confirmed that it intends to undertake a governance review that will align with any further review work to be undertaken by the Wales Audit Office.

And finally, I am seeking immediate assurance across Wales on the provision of maternity care. I've asked all health boards to consider the reports and how the findings may be relevant to their own services. I expect all health boards to provide assurance to me within the next two weeks. The chief nursing officer and the chief medical officer will work with health boards to ensure that the learning from these reports informs actions for Wales in the new five-year vision for maternity services.

There have been significant developments in recent years across maternity services in Wales—significant and positive. For example, OBS Cymru is a national quality improvement project that aims to reduce harm from bleeding following birth, and has received national and international accolades. Most women in Wales receive high-quality services and have a positive experience from pregnancy and childbirth. Nonetheless, many expectant mothers and their families will understandably be shaken and concerned by the reports published today.

As I said, the reports made for incredibly difficult reading, and they will do for all of us who take the time to look at the reports. At their core are mothers and babies, their experiences in pregnancy, during birth, and the level of safety that every family has a right to expect. The measures that I have announced today are the next essential step in ensuring that high-quality, effective maternity services are available to every mother and family in Wales.

I want pregnancy and childbirth and the maternity care that is provided to be a positive experience that women and their families can look back on and cherish.

Can I thank the Minister for his statement, and indeed for the briefings that have been made available to Assembly Members and their staff today? These reports make for very grim reading indeed. They expose some very serious shortcomings at the heart of an organisation, the Cwm Taf health board at that time, which failed those in its care. The staffing, the leadership and the governance issues have had tragic consequences, frankly, for mothers, babies and their families and loved ones, and those responsible for what went wrong must be held to account for it.

The culture in these organisations is set by the leaders in the organisations. That includes members of the board and indeed senior managers in that health board. I think that some of the information that has come to light following the publication of these reports—and I do welcome the fact that they were published in full in the public domain—is very alarming indeed. It's particularly alarming and galling to see that there had been some evidence of problems that was not relayed to the Welsh Government sooner, and shared with the Welsh Government, particularly the consultant midwife who undertook a review of some of the issues in relation to the reporting of serious incidents and stillbirths, which was clearly very inadequate. I do think that it calls into question the integrity of those senior managers who would have had sight of that report and failed to disclose it to the Welsh Government and indeed to your senior officials.

So, my first question is this: what action is going to be taken to hold those individuals to account for failing to disclose the very serious issues that were identified in that report, which was completed and given to the health board back in September? I'm also very alarmed that the report suggests that basic governance processes were not met. The risk register, it says, was not even updated since 2014—2014. We're in 2019, for goodness' sake. These are things that the board should naturally be focusing on in terms of reviewing those risk registers from time to time. So, what accountability have those independent board members, who you appoint, Minister, to you for their lack of focus on some of these basic processes that ought to be in place on any board as far as governance is concerned?

I note as well that the report goes on to identify a timeline of previous reports—no fewer than nine reports raising concerns over a period from 2012 right up to September 2018, all of which provided opportunities for intervention and an opportunity to lift the lid and expose some of the problems that clearly were beginning to emerge in those maternity services. Yet, time after time, it would appear that recommendations were not followed up, that the outcomes of those reports were not fully shared with the people that they needed to be shared with, and that the things that should have been implemented arising from them were not implemented arising from them.

It calls again into question the role of senior managers in that organisation, executives in that organisation, for not being able to share that information more widely. I would remind everybody in this Chamber that the consequences of those actions have been that babies have died. That is the reality. Babies have died. Mothers, fathers, families have lost their next generation as a result of what has happened at Cwm Taf.

I wonder also whether you can tell us what is going to be done by the Welsh Government to address the workforce issues, which are not just evident at this health board in this report but more widely across Wales, in terms of the midwifery workforce and indeed in terms of the obstetrics and clinician workforce to support those midwifery services. You will know that my party has raised, on many occasions, concerns about the fact that around a third of the midwifery workforce are going to be eligible for retirement by 2023, but at the current rate of replacement we are not going to be able to fill the gaps that are there in the midwifery workforce already, and which are now growing in terms of the positions that you are currently funding for training. So, we need to make sure that there is a massive increase, frankly, in capacity to make sure that the overstretched workforce that we have is not overstretched in the future. 

It is appalling, frankly, to see that there were times when doctors should have been available, but they were not available. They were on call, but wouldn't respond for three quarters of an hour. Now, in an emergency, every single minute matters. Forty-five minutes in an emergency is not acceptable, yet that's what we read about. We read about a lack of mandatory training being undertaken. As few as a quarter of the staff actually participated in some training courses. It's not good enough, and we need to make sure that there are sufficient people in these wards to be able to deliver the high-quality care that I know we all want to see. 

I'm concerned as well that the voice of patients, in terms of the concerns that they had raised, had far too often been ignored. And it was harrowing—absolutely harrowing—to read those patient accounts and some of the statements in there about the lack of dignity, the lack of respect, the flippant way, frankly, that some individuals had been informed of their babies' deaths. Absolutely harrowing. And I wonder what on earth is it about some so-called professionals that leaves them in a position to treat people inhumanely in the way that some of those people had clearly been treated by people in our Welsh health service. 

There's also a hint in the report about the important role of CHCs in being able to help manage—community health councils—the complaints process and perhaps be able to assist health boards in learning lessons from complaints. And I wonder whether you'll be able to tell us, today, whether you see an enhanced role for community health councils going forward in supporting health boards, in listening to the voice of patients and in implementing change when there are lessons that need to be learnt. 

And finally, can you also tell us, Minister: some of the things that I read in the report suggest to me that there need to be many referrals to the Nursing and Midwifery Council and to the General Medical Council about the lack of competence from some professionals. Will the Welsh Government, or will the Cwm Taf Morgannwg health board be making those referrals and, indeed, if necessary, will the police be informed and be asked to undertake a review, particularly given that medical records clearly were going missing and were inaccurate at times also? Thank you.

Thank you for the series of questions that I'll now try to run through. I'll try and deal with those matters that are broader and then some of the specific points that you've made. 

The matter in terms of regulators: ordinarily, you would expect referrals to be made by the employer, and I actually think it'll come back to some of the work that the independent oversight panel will do to identify what had happened in the 43 cases, and a broader look back to see if referrals are required, but we have ensured that the reports have been directly shared with both regulators, the GMC and the NMC, and referrals should be made as appropriate. But it's not for me to determine that individual referrals should be made, but I am trying to ensure that we do have a level of understanding to know whether that should be the case. 

In terms of community health councils, we actually have proposals to enhance the voice of the citizen across health and social care and reforming the way that they work, and that broader role across our continually more integrated health and social care system. I think those new proposals are outside the scope of this report, but with the current way that community health councils are constituted, of course they have a role in supporting people in making their complaints, and in the information we've put out today, we've been clear that community health councils are there to support families to do so. 

Coming onto your broader point about staff numbers, there are two distinct points, I think, to make here. One is that, on midwifery numbers, it's clear that there were not enough midwives within the service, and there's a challenge about when the health board itself recognised that it was not Birthrate Plus compliant, and that, of course, is the tool that is used to understand the right number of midwives to deliver the service.

Generally, within Wales we have found that our health boards have been Birthrate Plus compliant. The challenge about the future workforce that has been highlighted has been the need to do something to ensure that we recruit and train enough midwives for the future. It's part of my disappointment that the health board declared at a relatively late stage that it was not Birthrate Plus complaint. Of course, that was then re-highlighted in the report because the experience of staff has been that they were working understaffed, and patients and families recognised that themselves.

So, there's a job of work to be done immediately that is both about recruitment but also the way that health boards work together, not just within Cwm Taf Morgannwg but around them, to try to make sure that the units are adequately staffed as we try to both recruit and train for the future. But I have already recognised the need to train more midwives for the future, because, two years ago, I decided to increase midwife training places by 43 per cent. So, we are actually taking steps to make sure that, for the future, we're training many, many more midwives.

On the point about doctors, the numbers aren't actually the issue—it's the practice and behaviour that are the issue. The report sets out quite clearly that there is an adequate number of doctors in this part of the service—it's the way that they have behaved that is the challenge, and that, actually, is much more difficult to deal with in many ways. If you have the right number of staff behaving in the wrong way, then it still provides a challenge, and this report sets out that that is part of what has happened.

On your point about, in any event, the way that our staff behave, it's part of our expectation and we do not expect staff within the health service to be insensitive, unprofessional and to provide a lack of dignity for people who are often at their most vulnerable when they interact with the health service at any point, and that obviously includes people who are due to be giving birth or people who know that they may have a potentially poor outcome from their pregnancy. That was part of what I found particularly difficult to read in the report. It took me several days to read the report because it's genuinely upsetting.

On your other point about the internal report that the health board commissioned, which was provided in September 2018, it's plainly not acceptable that that report was not properly addressed through the board's reporting mechanism, that it was not provided to the board's quality and safety committee and it was not provided to the board, and action was not taken at that time. The health board chair and the chief executive have both recognised, in publishing that report today, that the health board got that completely wrong.

It's important to recognise what the health board has got wrong to actually make progress for the future. There is a question for the board that the chair is addressing, with a review led by an independent member of the board, to understand what happened at that time, why it did not come to the board, what can be a lesson in looking backwards but also what that means going forward. There are broader questions there about leadership and governance, not just to be addressed in that one individual instance—that's why the work that Healthcare Inspectorate Wales and the Wales Audit Office do will be important, and the broader support of what David Jenkins will be doing as well.

It is plain that there have been system failures within the health board—that's acknowledged not just within the report but in the briefings and statements that have already been made today. But the accountability for that is not a simple question of lining up a discrete number of people to be removed from the organisation.

As you heard the First Minister point out, the report sets out challenges and failings in a number of different areas within the service, from the direct contact with individuals to people who had an area of leadership and management responsibility, to the clinical direction of the service, all the way through to the advice, information and challenge provided at executive and board level by independent members. That is why I believe it is hugely important that there is independent oversight of the work that's required to implement the recommendations of this review, and that independence comes not just from looking at the 43 serious incidents in the 2010 look-back, but that that will then provide a proper evidence base for where accountability lies and how we move on.

There's something that is very difficult here, because the report highlights that there was a punitive culture within the workplace, where people were frightened and fearful of raising concerns. That is wholly inappropriate and in no way acceptable. To get to the point where people are more confident where they could and should raise concerns, we actually need to be open about people acknowledging now what went wrong, as opposed to people looking to walk away from that because they fear for their jobs. Actually, if we don't have that more open-cultured environment, we're more likely to compromise the quality and the safety that people who use those services have a right to expect. So, a fundamental change in the culture is what is required, that is why the independence I've inserted into taking forward those recommendations is so important. But I will, of course, report back to Members when there is more information to be provided about that work and the immediate assurance exercise that I've required to be undertaken. 

I'm obviously grateful to the Minister for the statements that he's provided, for publishing the report and for the briefing I was unable to attend in person but I have been able to speak to colleagues who were present and we're grateful to the Minister for that.

The Minister, of course, is right to say that this report makes for very difficult reading. I've only had a day to read it and it is very painful. Reading the pages, 30-2, that talk about the patients' experience—how disregarded, how distressed, how humiliated these women and their families felt at a time when they are most vulnerable. Any of us who have been through the experience of pregnancy and birth know that however confident and however pleased you are to be pregnant and however safe and secure your home situation is, you feel incredibly vulnerable at that time in your life. And as the Minister rightly says, the very least that women and their families can expect is that they are made to feel as safe as possible, that they're handled with sensitivity and dignity and, particularly when there is terrible sad news to impart, that that is done sensitively and kindly. 

It's also clear, and I think we should stress this, that the report sets out very clearly that there are good people working in that service—good people at the front line who are working incredibly hard to provide the best service they can in circumstances that are very, very difficult. I think we should acknowledge and express our thanks to those staff who have—I would suggest it's an overused phrase but I think it's appropriate in this case—clearly been lions being led by donkeys. They have been let down by systematic failures and it's not good enough. Terrible systematic failures—and the Minister talked about the deep cultural issues where people were disrespected, where the staff themselves were disrespected and they were disrespectful.

It is right, of course, Dirprwy Lywydd, that the Minister has apologised, and I'm sure that we are all glad that he has met some of the families and will continue to meet them and to take their views and concerns into account. It is also right, of course, that he accepts the recommendations. However, I remain unconvinced that he can be confident in delivering those recommendations. He cannot present to this Chamber today and to those families the idea that this crisis is some kind of a surprise to the Welsh Government. Darren Millar rightly highlights page 7 of the report, which sets out nine separate reports highlighting particular aspects of this issue from 2012 to 2018, and that in addition to the warnings that have been raised in this Chamber to the Minister by, among others, my colleague Leanne Wood, speaking on behalf of her constituents and the experiences that they've suffered.

Now, the Minister tells us that he's placing part of the health board into special measures. Well, those of us who represent part of the Betsi Cadwaladr health board area know that four years into those very special measures, the problems are not solved. The issues that come into my constituency postbag and I know that of others—my colleagues Llyr Gruffydd and Siân Gwenllian, for example—. Four years of special measures and the problems are not solved. So, I want to ask the Minister today, Dirprwy Lywydd, whether he accepts that there are some systematic problems with management in the NHS. Professional staff—doctors, nurses, midwives—have to have a given set of competencies, they have to be registered, we have to know that they're professionally competent. Is it not time to have that core set of competencies for people who are managing our NHS and a system of registering those staff, and particularly a system of registering those senior staff so they cannot fail in one local health board and pop up in another? There's a particular pattern of that happening across the border. I'm not suggesting that's relevant specifically here, but in terms of the systematic failures that we've seen, where people who have made a mess of things in English health management are fetched up making a mess of things in ours. Surely we need that core set competencies. We need managers and leaders who can be relied on. We need to know what's expected of them. Now, when it comes to accountability, I have heard, of course, what the Minister has said to Darren Millar, but the Minister himself has talked about needing to change the culture. Well, how can you change the culture if the same individuals who created that culture are still in charge of it? Now, I completely accept, Dirprwy Lywydd, what the Minister says about not wanting to create an environment that's even more punitive, but, unless people are held accountable, how can those frontline staff, how can those women and their families, be confident that their concerns will be addressed more sensitively if the same people are addressing them who have allowed this situation to arise in the first place? I'm not calling for heads to roll necessarily, but how can people be confident that things will change if no individuals are held accountable? In any other profession—in social work, in teaching—massive systematic failures like that would lead to people being replaced and I just do not understand why the Minister doesn't seem to feel that this is necessary.

Now, and I say this with much regret, Dirprwy Lywydd, but I have to ask the Minister whether he accepts that in our health system—and this is something I support and it's different from the position in England—the accountability for the running of the national health service in Wales rests with the Welsh Government and with the Minister. The legislation is clear about that. The Minister appoints the health boards, he sets their budgets, he sets their policies, and so should he in my view. So, finally, Dirprwy Lywydd, I have to say that, faced with this most recent, most serious failure, does the Minister believe it is time to consider his position to act accountably for what's gone wrong and resign?

The scale of the concern, as is set out in the report and in the timeline, was made properly aware when a new head of midwifery service actually reviewed the data within the service, and those concerns led to additional Welsh Government contact with the organisation and, ultimately, because I was not satisfied with the health board response, I decided to commission this independent review that has been reported today. So, from the scale of the concern being properly highlighted, by someone doing their job as they should do, escalating those concerns, we now reach a point where a Minister makes a decision—we have this report today. And it is an undeniable fact that, without that, we wouldn't have the objectivity in the report that we have today and the lid could well still be on top of these concerns that exist within this service. [Interruption.] When it comes to understanding the range of different reports, there are reports across a range of different services and then action is normally taken to resolve those. We actually found the scale of this concern—and, as I say, I've set out for you how and when I acted to ensure that the Royal College's review was undertaken.

Now, when it comes to special measures within the service area, we have a clear set of recommendations to work to for the service to improve against. We have independent oversight of whether those recommendations will actually be achieved and we are in the fortunate position where a number of families who have met with Welsh Government officials today and have received a personal apology from the chair of the health board are still willing to continue to engage in that work to improve services, and that is hugely important for us to be able to properly learn lessons and ensure that women's voices and their families are not forgotten in this, because, actually, what we need to do is enhance their voice in the future of the service. So, I think there should be some more positivity about how long the service area will remain in special measures, but I will say the service area will remain in special measures as long as it is appropriate to do so. I'm not going to set any sort of artificial deadline for special measures to end in this service area. There must be a proper and sustained improvement that is objectively highlighted and signed off, and it's worth pointing out that, in Betsi Cadwaladr, maternity services were one of the key concerns that led to special measures for the whole organisation and the service has delivered sustained improvement in maternity services and that's why they came out of special measures more than a year ago.

Now, on your point about management, I appreciate that some of what you had to say was not about the Welsh system at all, was actually a commentary on the system in England, but, of course, many managers are themselves clinicians. If you look at most of the executive team around health board tables in the country, they're registered healthcare professionals who still maintain their professional registration, but the job they undertake as leaders and managers requires a different sort of experience to being a clinician. And, of course, we do look at the relevant qualifications and experience upon appointment, and the health boards that appoint them do that as well. This is the point about our system having the boards to properly undertake the governance, the support and the challenge required to make sure the right people are appointed and in place. Part of what is difficult about this particular service is that, up to now, Cwm Taf has been a high-performing health board, living within its budgets and doing well when it comes to performance measures. But quality and safety is a non-negotiable part of the healthcare system here in Wales, and so the accountability that Members understandably call for—there will be evidence to underpin any form of accountability and the independent processes that I have set in place are not just designed to provide assurance to the public, they are designed also to make sure we understand where accountability should lie, because our objective is to change and improve the service, and that must require significant cultural change to do so. 

So, I'm not going to set out an artificial deadline for whether anyone should leave their employment; I am interested in people who are in the health service being able to do their job properly and to do their job with the public that they serve. But we have seen a change already—there's a significant change in independent members compared to the health board in 2010. Two doctors who were in the service at the time the report was written have now left the health board. Coincidentally, we also now have a new nurse director at executive level within the health board in place within this month. They're out to recruitment for a new medical director—again, that is a matter of coincidence; that was a planned retirement in any event. And there is also now, within the last two weeks, a consultant midwife within the service as well, so there is change, and significant change, within the leadership tiers of the organisation.

The challenge now is for people to do the job that they're paid for, the job they came into the health service to do, to provide the confidence and the quality that each and every family is entitled to expect. And, of course, I will not be resigning; I will be stepping up to my responsibilities as the Minister for the national health service here in Wales and seeing through the required improvements that I recognise must take place.

Thank you, Minister, for the statement. I have to say that I'm both shocked and saddened by what I saw in this report and the findings, and, like others, my thoughts, first and foremost, are with the families, many of whom are my constituents, of course, that have been affected by the failings in the Cwm Taf maternity services.

While I know that many women have had good experiences and good care within Cwm Taf, too many have not, and right now they have to be the focus of our concerns. There are many aspects of the report that I'd like to address with you, which include data accuracy, patient dignity, inadequate support for staff, lack of professional development training, reviews of serious incidents, poor clinical practice, inappropriate staff management, reluctance of staff to exercise their duty of candour and, of course, who actually takes ultimate responsibility within the health board. But, due to the limited time today, I will do that with you outside of this session and in direct discussions with the health board. Today, I'll just focus my comments on three particular areas and try not to repeat what others have said.

Firstly, the poor governance of maternity services in Cwm Taf is clearly of grave concern, and, whilst staffing levels are something that must be addressed, I have to say that, even if we had optimum staffing but those services are not properly managed, then we're still going to have the same problems. So, I'm particularly concerned at the statement in the report relating to false assurances given to the board by the senior executive team about the service, and I'd like to know what that means and what is going to be done about that.

Secondly, in relation to the decision in 2014 to move the consultant-led services onto one site, do you know what risk assessment was undertaken regarding the impact of staffing on that decision, given that most midwives based at the Royal Glamorgan Hospital would naturally look towards Cardiff or Bridgend and not Merthyr when considering employment changes? And why, as it appears, were the staffing issues consequent on that decision left to the last minute to address when the board has had five years to plan for it?

Finally, it will be vital to ensure that the service is not destabilised during this period of intervention, so what assurances will you and the health board be giving to prospective mothers about the safety of maternity services in Cwm Taf now, and how that will be communicated

Minister, within the Cwm Taf area, many of us will have both a political and a personal interest in ensuring that maternity services are fit for purpose, and, indeed, my first grandchild is due to be born at Prince Charles Hospital in August, so, while I welcome the proposed actions set out in your statement, what are the timescales within which you expect the health board to deliver the changes that are needed?

Thank you for the comments and the questions. I think you're right to point out that, of course, there is a great deal of good care that takes place every single day in every single community across our national health service, and the report does highlight a range of staff who provided good care, in particular in the community midwifery service, but it is entirely right and appropriate that we focus on the failings identified in the report today. And that does come back to your point about the management and the culture within different parts of the service, so not just at the most senior level, reporting in to the executive team and the board, but from the shop floor and all the way through and leaders and managers in different parts of the service. The report talks about a punitive culture; I would expect the trade unionists to talk about a bullying culture, and a culture of fear within the organisation, and I recognise that on reading the report. So, it isn't just one part of the culture within the maternity service in the board that needs to be addressed. And that does come back to your point about false assurances being provided, because the report sets out quite clearly that a range of concerns were suppressed and not dealt with, and reports were not then properly concluded, so, actually, people were being provided with an assurance that wasn't accurate, and I think independent members took assurance where it should not have been provided to them in that place. That is a question not just that the report sets out, it's not just a question that will be addressed in the independent review on what went wrong, as well as making recommendations for the future, it is part of what the board needs to address now. I've spoken several times to the chair of the health board and he understands very well that it is a question for the board to address adequately and properly themselves as to what information they had, what they didn't have, and what they will require to have in the future and the level of challenge they must have. That is part of the work that David Jenkins will be doing in supporting the board to do so.

In terms of your point about the move, the move to the concentration of consultant-led care at Prince Charles—you're quite right—has taken a long time to happen, longer than it should have done, frankly. And part of that is because the health board, but also the two units in question, were not determined to make the move happen in a collaborative manner. When the report took place, they still found culture between the two sites that was not accepting of the move that was imminent. And that's a real problem from the leadership teams within the doctors on both those sites. And that's not acceptable.

So, the move, and, prior to the move, there was a multidisciplinary meeting that took place, and there were two Welsh Government officials in that meeting, which confirmed that they were in a position for the move to go ahead and that, actually, there was less risk to staff and the service in going ahead with the move in March than in putting the move off and in trying to run consultant services on both sites, partly because of the fragility of staff in midwifery, but also the number of locum staff within the medical grades as well. So, yes, there was oversight, but there's still more work to do to make sure that that service is the sort of service that you or I would want for ourselves and obviously for your first grandchild.

When it comes to women and their families being supported, they should contact their midwife and contact their health boards to talk through concerns and fears that they have, to understand the options that are available to them, and to make sure that they do so as soon as they are concerned or worried, because that is part of the role that the midwife has, to support women to make their choices. Some women may want to choose to give birth in different settings, whether at home, whether it's water births, or whether it's in consultant-led care or in midwife-led care, and some people may want to think again about the location of their birth. Now, I would want to encourage the take-up, in the first instance, of all of those concerns with their community midwife, and, for the health board, it's a very clear expectation that they support women to make those choices of where they are most comfortable, where they feel best supported.

And, in terms of the timeframe for improvements, well, improvement has to take place immediately. Immediate improvements are required, but I should not pretend to you or anybody else that this will be resolved quickly, because the cultural change that I've highlighted on more than one occasion will take many months to actually be in place and then to be sustained thereafter.

I've got a number of speakers now, and I will extend this statement. However, the major parties have had their first speaker, and I've been quite lenient with timing, so I will ask all the other speakers now just to address the statement and ask a brief question. That way, we'll probably get everybody in without overrunning for too long. Andrew R.T. Davies.

Thank you, Deputy Presiding Officer. Minister, thank you for the briefing that you facilitated this morning for Members and, in particular, for the apology that you have offered in your statement this afternoon. I think it is wholly appropriate, and I welcome the remarks that you made about how difficult you found reading the report. It is a very difficult report to read, because, ultimately, you are talking about something that should be a joyous occasion and, sadly, for some families, it turned into a horrendous experience that no-one should ever have to go through. And this is happening in twenty-first century hospitals, sadly, not too far from this very institution.

One thing I would like to put to you, because most of the ground has been covered, is the issue of governance and supervision, because I think that goes to the crux of the matter here. At the very top of the recommendations or concerns there is the lack of consultant availability, taking 45 minutes to come to a hospital when required. There's the inability to make evidence available until the inquiry team turned up at the hospital itself, from the board. There have been nine different reports, I believe, from 2012 to 2018. In fact, on page 11 of the report, the report authors talk of their dismay

'that the Health Board had received information highlighting areas of unsafe practice' yet chose not to take any action when this evidence was presented to them.

I think what is of critical concern here is: when is this culture going to change? I hear what you said to date—it takes time to change that culture—but this isn't a report in isolation. This is a report built on nine previous reports, and there has been a cataclysmic failure of governance in this particular health service, in this particular discipline. And I do question whether it's isolated specifically to this discipline, maternity services, or if it's a wider issue. It cannot be right that there cannot be fundamental change in this health board, because if that change is not delivered at the top of the health board, then, really, we will be back here in two, three, four years' time, reviewing the same sad report that we're looking at this afternoon.

As I say, I do commend you for the apology you've put on the record. I think some families will find comfort in that. But we cannot and must not allow this to be another report that isn't acted on and, as I said, we're back here in two or three years' time.

I have absolutely no intention of coming back here in two or three years' time and having to report that no further progress has been made. That's why I've taken the steps that I've confirmed today and given the assurance of independence in reviewing the progress that the health board has or has not made. Because I will be honest about the level of progress that has or has not been made by the health board every time I report back to the Chamber or to the wider public.

Again, I go back to the point about behaviour and culture, because when you talk about the report highlighting that doctors weren't available, that's a point about the medical culture, because that wasn't about the numbers of people employed within the service, it was actually about their working practice. In many ways, that is much more difficult to address, which is why I said to Dawn Bowden that we are talking about many months of work to change the culture to a point where it is more likely to be sustained and changed, and I'm under no illusions whatsoever that significant change is required within the organisation.

The work that I've highlighted is not just confined to maternity services. There is new clinical leadership within the medical team within this part of the service, there's a new clinical lead in place, and that's a positive step forward. But the work that Healthcare Inspectorate Wales are going to be doing is looking more broadly at leadership and governance within the organisation, and I'm expecting their report to be available before the end of the autumn. I've had a conversation with the chief inspector of HIW today, and that is my expectation following the conversation with her—that she expects a report to be available within the autumn.

Again, HIW reports are published and there is no hiding away from them, and so we'll be clear about what level of change has or has not taken place and what further change is still required. I would expect that we'd still hear at that point what further change is still required to make sure that that change is real and sustained. So, I'll return to this Chamber and/or committees that do or don't want to ask questions about this, and as I said, I'll be honest about where we are and about what we still need to do.

I attended the briefing this morning on this, and there wasn't enough time for me to ask questions there on behalf of my constituents in the Rhondda, so I hope I will be afforded the time now, Llywydd.

It's good to have an apology from the health Minister, and, I have to say, when I first read this report, which refers to a culture of people's concerns being dismissed, I immediately thought that this could also apply to the health Minister. I have lost count as to how many times I have raised on the floor of this Chamber, with both the health Minister and the First Minister, my concerns about staffing shortages and complaints in my local health board area. I have to say, most of the time, these concerns have been dismissed, or at least not taken seriously. Yes, the health board has to do better on a whole range of areas, but Minister, so do you.

It's not good to read that 67 stillbirths, going back to 2010, were not properly reported, and it's appalling to read how some patients just weren't listened to. I wonder how much of a problem this would have been in a more affluent area. Poorer people's views are often easily dismissed across a whole range of public services. So often do I hear about people being treated differently to how those from middle-class backgrounds would have been treated—people who may have gone to university and know very well how to demand their rights. This principle is known as the inverse care law, and it's been recognised and acknowledged by the medical profession. Minister, will you agree to look to see if this has been an issue in this instance? Please feed back to us.

These are my further questions. Will you agree to look seriously at every complaint and every serious case that has not been dealt with satisfactorily? Given that this report talks about a problematic culture, a punitive culture with regards to complaints, I strongly suspect—and my case files back this up—that failing to deal with complaints is a much wider problem. Do you agree with that point, and can you tell us exactly what you are going to do about it? Because I didn't hear anything specific in your statement addressing that point of culture. I welcome the fact that you are going to look into other departments. What messages can you give to worried parents-to-be, like the constituent of mine who is due to have her fifth baby and has seen the services decline over many years, and now is very worried about the care she is likely to get? Can she opt to go somewhere else, for example? Will you agree to closely monitor the situation at Prince Charles Hospital? I've had contact with many former Royal Glamorgan patients who are not happy with what they've experienced in Prince Charles Hospital over the last six weeks or so.

We in Plaid Cymru campaigned from 2013 against moving and centralising these maternity services, and we've campaigned against the moving of the children's services, which are due to move this summer. Doctors have told me their concerns about all of this as well, one telling me of their belief, and I quote, that mothers and babies will die. This report confirms that staff agree with us about centralisation, and have been prevented from speaking up. Will you listen to the staff that say that this centralisation is risky? Will you now listen to what patients are saying on this, and will you agree to monitor and work to reinstate those services at the Royal Glamorgan Hospital if the situation continues to be a risk and people continue to report problems?

I'll start by reiterating that I'm not going to defend the failings identified in this report. That is absolutely not what I'm going to do. It would be wholly inappropriate for me to try to do so. The challenge is how those failings are addressed, and we have a wide number of recommendations to do so. As I've said repeatedly, having a proper independent process to do so is really important, not just to the health board, but actually to the public that the board is there to serve, because no family should be treated in this way, regardless of their income, of their educational status, where they live. No family should be treated in the way that the report sets out.

If you actually look at similar communities—for example in the Gwent valleys—you don't hear the same story. We don't have the same level of concern. If you look, for example, at practice—and it goes back to culture and things that I've raised and described in many of the responses to questions today—the intervention rates within the former Cwm Taf health board are significant and different, and the report highlights that. It is not explained by the socioeconomic group of people they're dealing with. It is not explained by comorbidities in health, because, actually, similar communities have different intervention rates in terms of induction, caesarean section and assisted delivery. And that comes back to culture within the unit and the practice, and that is part of what has to change. Otherwise, we'll have women taking more risks than they should do in giving birth, potential complications afterwards, and it will change the mix of the staff and the beds that we need to properly service that. So, actually, it's really important to change around a better service and a safer service within the area and a better use of all the resources that we have. It comes back to why the independent review of the 43 serious incidents and the look-back to 2010 is important.

But I just want to finish on your point about supporting women to make choices. Yes, as I said, I expect them to be supported to make choices. And there are other consultant-led units that are not in Prince Charles where women may want to give birth, but they should start, as I said in response to Dawn Bowden, by discussing that with their community midwife to talk about fears or concerns they have and the choices that are available to them.

I don't agree with you that going back and trying to unpick the south Wales programme is the right thing to do. The concerns that existed then about fragility within our system in trying to run a larger number of sites than our staff and the case mix provides—I don't think that's the right way forward. What we do have to do is to understand the information that we're given by both staff and by people using the services, and to understand what we need to do to properly equip the service that we have in terms of capacity and staff numbers and, crucially, practice and culture.

Thank you for your statement today, Minister. As a mother myself who's given birth within the Cwm Taf area, as well as being an Assembly Member for a constituency that falls under the Cwm Taf area, I can honestly say that this report is the most distressing thing that I have read since I was elected to this place three years ago, and my thoughts are very firmly with the families that have been affected.

I'd like to add my support to comments previously expressed by other Assembly Members about the impact of these tragic consequences, the nine previous reports and missed opportunities to put things right and the urgency to put things right now. I'd also like to pay tribute to those really hard-working and dedicated front-line staff who will be feeling very vulnerable with the publication of this report today—many of whom I met when I visited the new service at Prince Charles hospital recently. From the mothers who gave evidence to this report, one theme stands out very strongly, and that's the fact they wanted to give their evidence in order to put things right for future mothers going through the service. The two areas of questioning that I'd like to focus on today are very firmly linked to that.

Firstly, for all the women that I have spoken to from my constituency and also the women from Cynon Valley whose views are expressed in the report, there's one theme that stands out very clearly, and that's the issue around notes disappearing, or record keeping not being accurate, and women going through a very difficult time in labour being repeatedly asked by different members of staff to verbally pass on information rather than the information being there at hand. Now, you'll be aware that on the Public Accounts Committee, we have been undertaking an inquiry into NHS informatics, and I wondered whether, as part of the next step after this report, it would be appropriate to consider whether informatics could be used more effectively within the Cwm Taf maternity service, in order to ensure that all the information that midwives and doctors need is at hand in order to make the right decisions at the right time for mothers and for babies. 

Secondly—and this is an issue that you've touched upon in your reply to the previous Assembly Member—we know that the Cwm Taf area has particular issues around its socioeconomic make-up and resultant health issues that arise from that, but there are other areas of Wales that have those same challenges. What work can be done to link up the service provision in Cwm Taf with other very similar areas of Wales where they have fewer interventions in labour, which we know then leads often to safer outcomes for mothers and babies?

Thank you for the comments and the questions. Again, I welcome the point you make about staff. There will be many staff who will be concerned going into work today and looking to go into work for the rest of this week. There's a point about how we support staff, about how we still have high expectations of how staff behave, and how they are to be supported to work in a much more open environment.

I completely recognise your point about families wanting to see improvement. Many people said expressly they came forward to tell their story because they didn't want it to happen to someone else and they wanted the service to be improved. That does go back into record keeping—one of the concerns that I recognised having read the report as well. I do think the better use of what is no longer new technology but standard technology in large parts of our life is part of doing that, to provide a greater robustness and certainty about record transfer and actually taking a more proactive approach to capture the views of people as they're using the service as well. So, I absolutely do think that is a standard part of the future.

Crucially, it goes into your second point about support from other health boards who serve similar communities. Because actually there is already good practice that exists within the system here in Wales on the doorstep of the former Cwm Taf area, and it's important to me that that is properly accessed and taken on board in improving the service within the former Cwm Taf area to make sure that we don't wait months and months and months to make no progress, but that the immediate improvements that could be made, we're clear about what those are and the support that's provided for people who are running midwifery at the services, who are running maternity services in very similar communities with different intervention rates and different outcome rates.

Minister, I've been in two minds all day as to whether to speak this afternoon, but I feel it would be wrong for me to sit here as someone who herself had really poor care from Cwm Taf health board when I had my first child and say nothing. I have largely tried to blot out my experiences in Prince Charles Hospital with my first baby, but suffice to say that the stories that I've read in these reports about mothers feeling ignored, not listened to, dehumanised and made to feel worthless are ones that I very much can relate to. Having read the reports today, I also feel even more lucky than I did 16 years ago that I came out of there with the lovely boy that I've still got today. 

I do agree with Leanne that there is a very significant inverse care law at play here, because I simply don't believe that these cases wouldn't have come to light sooner in a more affluent area, and I hope that that is something that you will look at in response to what Leanne Wood said.

I also wanted to ask you about the cases pre 2010, which covers the period that I had care at Prince Charles Hospital, but will have also covered the experiences of many other mothers. I think that if we can take anything from this report it's that we have to hear the voices of those who have had poor care. So, I'd like to ask you, Minister, whether you are confident that the time frame you're operating within will actually pick up all the cases that you need to, especially in view of the fact that the health board has clearly tried to conceal some information from the Welsh Government. I think it's vital that, if necessary, we do go back and look even further back in time to make sure that all those voices are heard and that we can genuinely learn the lessons from those times. 

Of course I do take seriously what happened and why, and finding out what happened and why, which is why I've set out independent steps to do so. That includes your point about the time frame to look back as well, because that's the recommended period within the report to look back, but it's very clear to me, and it'll be clear to the independent panel, that if they believe that there should be a different look back or a further look back then they will come back and tell me that. It would be an extraordinary failing of me if I decided not to take up that advice if that were to be offered, but that has to be a view that comes from that independent group. And we've had recommendations and suggestions from both royal colleges about independent people to undertake that review, for the clinical expertise. I hope to be able to announce that within a period of a few weeks, about who those people will be. And I think that should also help to give some confidence to families, because, in feedback from the families' meeting this morning with officials, part of the feedback was that some of them were concerned that it would be covered over and that the report wouldn't be as honest as it had been in reflecting accurately what they said. And they have said they have some more confidence that something is going to happen because the report accurately reflects the concerns that they've had. I think it's really important to keep those families involved and engaged in the work that we're doing and, crucially, ongoing work then, and the work that the health board is doing making sure they're listening to people's recent experiences of pregnancy to try and understand what's worked well and, equally, what hasn't worked well too. But if the independent review, the independent panel suggest we need to take a different look, then I'll certainly report that back to Members, with my own decision on that. 

And finally, Suzy Davies. 

Thank you very much, Dirprwy Lywydd. Minister, of course, you'll be aware that Bridgend, the Princess of Wales Hospital in Bridgend, is now part of the Cwm Taf area. When the consultation took place for Bridgend to be incorporated into Cwm Taf, I'm pretty sure that nobody who responded to that consultation was aware of what was happening with maternity services in Cwm Taf. I wonder, then, if you could just reassure my constituents in South Wales West that the Princess of Wales Hospital will not be affected by any steps taken through these special measures, a status that's been imposed on Cwm Taf now, and if people are going to be moved from Bridgend, in terms of their expertise, to other parts of the Cwm Taf area, that money will follow or, preferably, that nobody will be removed from the Princess of Wales Hospital's maternity and neonatal services in order to solve problems in other parts of Cwm Taf. 

I'm happy to confirm that if people move within the health board, then the health board will need to make sure that they adequately resource the service, if people are moving around to cover challenges in other parts of the area. But it's entirely possible that people will move from the current Bridgend area. For example, the medical director post: it's possible that could be someone from the Bridgend area, it could be someone from the former Cwm Taf area, it could be someone from outside the current health board. So it's entirely possible staff will move and their roles will need to be filled if they do. But I do want to confirm in a very straightforward manner that special measures do not apply to maternity services within the Bridgend area of Cwm Taf Morgannwg; they are not affected by the decision I've made today on special measures. But, of course, the broader questions about leadership and governance affect the whole health board area, and that's part of the cultural shift that is not just about maternity services but how the whole health board operates. 

Thank you very much, Minister.