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?