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.