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.