The Wales Audit Office produced a memorandum in 2015 setting out clearly the accountability arrangements for the NHS. These roles are in the memorandum, in line with the legislation, and these are the roles that are attributed by that memorandum to the Minister, setting policy and strategic framework direction, agreeing in Cabinet as part of collective discussion overall resources for the NHS, determining strategic distribution of overall resources, setting the standards and performance framework, and crucially, Llywydd, holding the NHS leaders to account. We submit, Llywydd, that in this last regard the Minister has failed in his duties, and his failures had serious consequences for the people. It is our duty as an Assembly to hold him to account for this.

We discussed the Cwm Taf report at some length here last week, but I feel I must return to some of the issues raised. The experiences of families caught up in this situation have been truly terrible, and children's lives have been lost. The report highlights amongst other things the lack of consultant cover, the use of locum staff without effective induction programmes, the lack of awareness around appropriate action in response to serious incidents, and, crucially, a governance system that does not support safe practice, and a culture within the service that is still perceived as punitive. It is also clear that many families were treated with shocking disrespect and disdain, and that there was a culture in some wards and in some circumstances where the dignity and respect that should have been accorded to mothers and their families was shockingly and absolutely absent. That there was catastrophic failing in this service—of that there can be no doubt. The question for us today is: could and should the Minister have known and acted sooner?

The report lists eight separate reports between 2012 and 2018, any one of which should have been enough at least to trigger a close look, if not an intervention, by a Minister and his officials. I will not detail them all here. They are in the public domain and the report, which I am sure all Members will have read. Now, the Minister's defenders will undoubtedly say that some of these reports are internal, and that the report itself highlights a lack of transparency on the part of the board, and this is true. But the majority of these reports were available to the Minister and his officials. In 2012, the Healthcare Inspectorate Wales report raised serious concerns around the quality of patient experience, delivery of safe and effective care, and the quality of management and leadership. Questions should have been asked then.

The 2007 General Medical Council deanery visit identified six areas of concern around failings in the educational contract, including induction. The 2018 General Medical Council survey raised concerns with induction and clinical supervision. These reports, coupled with concerns being raised at the time by individual Assembly Members as a result of issues being brought to them by their constituents, should have shown the Minister and his officials a pattern. He should have stepped in sooner, and if he had, many families could have been saved the trauma and loss that they experienced in this failing service. So eventually, in the autumn last year, the Minister did take action. Reports were commissioned, and eventually that work went under way, though given the severity of the concerns, it seems pertinent to ask why a review commissioned in the autumn did not take place until January. We know, of course, what that review found.

So, how has the Minister responded to this? Well, he has apologised. He has placed the service into special measures. He has sent a board in to provide advice and challenge and he has spoken about the need to change the culture. But he has left in place all those senior individuals who presided over the development of this disastrous culture. The chief executive, who has held her role since 2011, has been allowed to remain in post. As far as we know, and more importantly, as far as the families know, no-one has been disciplined for allowing this situation to develop and continue. No-one has been held to account for the trauma to the mothers and the deaths of 26 children.

The Minister will no doubt be aware that there is extensive research in how to deliver effective cultural change within organisations. He should know that one of the key factors in delivering effective cultural change is fresh leadership—change at the top. Does he really expect the staff who were working in circumstances where it was impossible for them to raise concerns to believe that their managers want openness now, that they will be encouraged and supported to be open about service failings, by the same managers who silenced them before? Does he expect the families who have raised concerns and continue to feel ignored to believe that those same managers who have patronised them, belittled them, and in at least one case threatened legal action against them, will suddenly start treating them with respect and taking their concerns seriously? Are we expected to believe that these leaders, who have perpetuated a culture of silence and who have allowed terrible mistreatment of women and their babies to continue, are we to believe these people have suddenly come to the conclusion that openness and honesty is best? I doubt it. So, while the right things have been said, effectively nothing has been done and the families deserve better.

Now, I have focused my remarks on the Cwm Taf situation since this is the most recent and most grievous of the failings the motion highlights. Colleagues will speak to the situation in the north where Betsi Cadwaladr health board has been in special measures for four years without the necessary improvements having been achieved. Members will also recall the independent review of the Princess of Wales Hospital and the Neath Port Talbot Hospital in 2014 also highlighting serious failings. 

What all these situations have in common is a failure on the part of the Government to hold senior managers to account. While front-line staff can be struck off and prevented from practice, managers appear to be able to move from one part of the service to another with impunity, with no sanction, regardless of how poorly they have performed. How can the Cwm Taf families and the front-line staff believe that there will be real change when, after four years of special measures, Betsi Cadwaladr continues to need intervention? This will not do. 

We need a professional body for NHS managers with the ability to strike managers off for poor performance. We need to ensure true independence of Healthcare Inspectorate Wales. We need a legal duty of candour to apply to all health professionals including managers, and a genuine, robust and transparent complaints system that supports parents and families. Some of this has been promised, none of it has been delivered. A culture persists where it appears that managers are never held responsible. This is not new and it must change.

The Minister has presided over this service first as Deputy Minister and then as Minister since 2014 and the culture has not been challenged, let alone transformed. The Minister must take responsibility, and if he will not do so we must hold him to account. Presiding Officer, no-one doubts that any health Minister serving our nation has a very difficult job to do. She or he is accountable for a vast and complex service, a service that spends the lion's share of this Government's budget, and a service that is vital to every single one of us as citizens and every person that we represent.

We have to be able to rely on a health Minister to provide the service with really robust challenge, to ensure that where there is failure it is addressed, and where there is best practice it is shared. Instead, we have a series of serious failings with no-one held to account. There must be accountability for this series of failings and for the inadequate response to them. So, Presiding Officer, in the spirit of all seriousness, I must commend this motion, unamended, to this Assembly.