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.