I do, though, want to set out what I will not do today. I will not be drawn into trying to unpick a selection of reports over the last five years of our NHS. Each of those reports was upsetting in its own right. Each one was incredibly difficult for the people affected. There were lessons to be learned from all of them: lessons for our NHS; lessons for our approach to intervention and escalation. So, I am not going to trade on examples of NHS performance, to point fingers at other people or other parts of the NHS in the UK. I'm clear that a party political fist fight, just a week after the report was published, takes all of us away from what families have told us really matters. Our job is to listen to them and to put right what should not have gone wrong, and that is why we have tabled our amendment.

None of us can truly understand how distressing this has been, and continues to be, for the families affected. But, I have been struck by the dignified way in which they have responded. The level of commitment that they have shown in expressing their wish to work with us, to inform and shape the improvements required in maternity services, is testament to that. My priority now is to take every necessary action to meet their expectation that this does not happen to other families.

The independent oversight panel will be key in providing that assurance. Mick Giannasi, as panel chair, has begun his work immediately. I spoke to him yesterday, and he fully understands the responsibility of his role. Mick Giannasi and Cath Broderick, the author of the families report, will join with me next week when I meet the families. I want those families to have their say in shaping the work of the panel, but I also want to thank them personally for the way in which they have engaged with the review and for being prepared to share their experiences. I hope that they can take some comfort in knowing that they are being listened to, and that action will follow.

There is no denying that the standards that became the norm in parts of these maternity services are completely unacceptable. The failures in governance processes that meant that outcomes were not escalated to the board are equally unacceptable. I have made it clear to the health board Chair that I expect him and the board to fully consider how this happened, as it is a critical part of ensuring that we do not see a similar system failure in the future. I expect Cwm Taf Morgannwg board to do everything necessary to have robust governance arrangements in place from ward to board, and David Jenkins's role is to help them to achieve this.

The overriding requirement is to ensure the safety, care and well-being of mothers and babies receiving maternity services. That must include the more open culture and practice that Dawn Bowden identified, to replace the punitive culture that the report describes. It must equally include the improvements in practice, experience and outcomes that Vikki Howells referred to. The improvement that we all seek must be rapid and sustained, and that will be the driving force that guides my actions as I discharge my responsibilities. I'm determined that the whole of NHS Wales learns from these system failures. I'll make that clear to health board Chairs when I meet them tomorrow. They have been given two weeks to review the report's findings and report on their own services. So, I will receive those reports next week.

We all know that the vast majority of people receive excellent care from our health services, but there are occasions where things go wrong. That is sadly true of every healthcare system. We have shown that we will take decisive action to identify and respond to failings when they arise. We've learned lessons, developed and then adapted our approach to escalation and intervention as a result. We've commissioned research from the Wales Centre for Public Policy to further help inform our approach, drawing on international comparators, and we reflect on our own experience. So, I'm far from complacent. I will continue to take the advice of regulators, the independent panel, my officials and, as I have said, to seek the views of families as we respond to the failings identified by this report. So, I will continue to act.

I recognise that women and families, Members in this Chamber, and the wider public will continue to expect transparency, to see the actions identified by the independent royal colleges review fully implemented, to hear that maternity care in the former Cwm Taf area is safe, dignified, and meets the needs of women and their families, and to see that evidenced by the independent panel and by those receiving care. To see and hear the outcome of the independent panel that I have appointed. That independent panel will therefore report regularly, and I confirm that I will continue to update Members and the wider public on their work and their recommendations for future action.

As Members are aware, the work undertaken by the independent panel and David Jenkins will be complemented by the work of Healthcare Inspectorate Wales and the Wales Audit Office. Those bodies are independent of Government. They will set the terms of their own activity for themselves based on their analysis of the issues. And their findings will, as usual, be published.

Over the past week, there have been calls from a range of opposition Members for somebody to be sacked. As a result of the action that I have taken, the independent panel or board may find evidence of conduct that requires action by the employer or a professional regulator. In those circumstances, I expect them to act appropriately, but I have not—and will not require them to take action for my benefit. Their remit is to help improve our service, to help better serve our public. There are no silver bullets. That is why I chose to take the approach that I have announced. I made a choice, and I will not go back now to look for an alternative scalp for my benefit, to give false assurance, to give a false impression of a quick fix that would do little to deliver the improvements that women and their families expect and deserve.

A week ago, I published in full the independent royal colleges report that I commissioned. I set out the action that I am taking. I believe that women and their families who have been let down, women and families who still need maternity services, must be our focus. They certainly are mine.