I was looking at one of the reports referred to in the motion in preparing for this debate today, and that mentioned how there were problems in terms of how senior management had acted in dealing with the risks that exist within the service. The report mentions huge problems in terms of reporting serious incidents, that there were delays in responding to complaints and, in some cases, those complaints received no response whatsoever. Well, what report was that? Well, the Ockenden report, or one of the Ockenden reports, on Tawel Fan. I looked at another report then, which echoed many of the same messages: an adversarial complaint system with slow management, problems with institutional issues, on patient safety, on developing capacity, on workforce planning, and some examples of appalling patient care. That was the Andrews report, referring to the Abertawe Bro Morgannwg University Health Board from 2014. And now, of course, we have the royal college report, which demonstrates once again that staff are overworked and are led by managers who don't deliver their roles effectively, that there is underreporting of serious incidents. The report demonstrates that patient safety is not a priority in terms of the decision-making process and that staff are reluctant to report concerns about patient safety because of fear of being barred from work over a period of time or facing disciplinaries for reporting concerns. And there are also concerns about the complaints process that are, again, outlined in this report.

The current Minister, of course, has been responsible for running the NHS on a day-to-day basis since September 2014, because that was his role as Deputy Minister at that time. And just a matter of months after the publication of the Andrews report on ABMU, and around the same time as the first Ockenden report was being drafted, was when he took up his role. And it would be reasonable, of course, for us not to blame the Minister for failing to halt the scandals, but he does have a responsibility for his response to them.

In my region of north Wales, of course, the Betsi Cadwaladr health board, as we've already heard, has been placed in special measures, and that was at a time when the First Minister was the Cabinet Secretary for health. That was supposed to be a temporary measure. Four years later, under direct management from the Welsh Government, and we still haven't seen the improvements that we would all hope to have seen when they were placed in special measures. Indeed, there is terminology similar to 'special, special measures' that has been used since then, and that is a cause of concern for us all. The board has faced a number of scandals over the years. One of the first issues following my election was the C. difficile scandal at Ysbyty Glan Clywyd, if you recall, and that was a number of years ago. But not a single member of the board or a single senior manager has been disciplined for that failing.