We heard last week from Lynne Neagle that there had been problems in Cwm Taf over 16 years ago, and, clearly, we have to ensure that the problems that were identified then were then rectified, but, clearly, that doesn't appear to have been the case in that what other people are saying is that there continued to be problems throughout all this time. The question that I asked myself on reading this report was, 'Where was the supervisor of midwives in all this?' Because it was their duty to ensure that a unit was safe, and, if it wasn't safe, they had the powers to close it down. So, that is a big question mark that I'd like to have answered, because it isn't—. Their role was then changed in 2017, so that they wouldn't any longer have those investigating powers, but would instead be there in a supporting role, and that is, indeed, what midwives wanted. And Wales was, to some extent, ahead of the game in clarifying the role of the new clinical supervisors of midwives. But my understanding is that, in Cwm Taf, the role was never changed in line with the legislation, that they continued to be asked to investigate serious incidents as opposed to being tasked to support and develop good practice in midwifery. There were clearly lots of examples of why there were concerns about midwifery practice, because of the numbers of stillbirths, the numbers of caesarians, which should have been evident to the board at the time.

And, clearly, if neither the—. It's not fair on midwives, who are there to deliver normal births, if they don't have then the specialist people to call on when complications start to appear. The fact that the consultant obstetrician was often absolutely absent and was not available for up to an hour, which is a huge amount of time when a pregnancy is going wrong—. It was clear that the service—. It should have been clear, in plain sight, to all the very senior staff—the consultant obstetrician, the consultant paediatrician—that this was not a service that was equipped to look after the very immature 28-week gestation babies. And the whistle should have been blown by them.

I think the key moment occurred when the consultant midwife reported in September 2018, and it was clear that it was hidden from plain sight, because the assessors who went up there in January weren't even aware of it until the day that they arrived. But is it the case that the board didn't know about it, or they did know about it and they did nothing about it? Clearly, the Minister did know about it, because he then commissioned additional investigations in October last year. So, he took appropriate action, in my view. But I think that there are some very serious issues that shouldn't be blinded by trying to put on trial the health Minister. It's all of us who have to accept our collective duty to ensure that health boards have the powers, the remit and the responsibility for delivering the service for the community they've been tasked to serve.

So, what changes, if any, need to be made in the governance arrangements of health boards, and how do we ensure that the culture within health boards is one that strives for continuous improvement and better meeting the needs of populations? We have to ensure that staff on the wards are in an environment where they can blow the whistle if they do not think that the service is operating safely, and that clearly does not seem to have been in operation in Cwm Taf. So, I think those are the issues in front of us. I think that calling for the resignation of the health Minister is, frankly, a diversionary tactic. We absolutely have to get right the service—