I would like to begin my contribution this afternoon by joining with my colleague Dawn Bowden in thanking the Minister very sincerely for taking such decisive action as soon as the issues in Cwm Taf maternity services came to light, commissioning this independent review that has allowed us to shine a spotlight on the failings in the service and begin to put things right. So, for my contribution today, I'd like to pick up on two important themes that I mentioned in the Chamber last week, and I will focus my remarks on the Cwm Taf report, as that's the one that directly affects my constituents in the Cynon Valley.

As I stated here last week, there's no doubt that, since I was elected to this place three years ago, that report is the most distressing thing that I have had to read, and my thoughts remain very firmly with all of the families affected. Firstly, for all the women that I have spoken to from my constituency and also the women from Cynon Valley whose views are expressed in that report, there is one theme that stands out very clearly, and that relates to the issue of notes disappearing or not being taken, of record keeping not being accurate, of women going through a very difficult time in labour and repeatedly being asked by different members of staff to verbally pass on information, rather than that information being there at hand. Take the example of Mountain Ash resident Joann Edwards. Joann has spoken of being constantly asked to repeat reasons for induction and type of delivery, and noted poor communication between staff and shifts. As she said,

'Not one person seemed to refer to my notes which even included scan pictures from the consultant with details of fluid measurements.'

Or Chloe Williams from Ynysybwl—now, Chloe had contracted E. coli during her pregnancy, which wasn't captured in her notes. She suffered tremendous pain and, tragically, her son was stillborn. Now, the reason that I give these examples in such detail—as Members will be aware, the Public Accounts Committee recently considered NHS informatics and had some pretty clear findings on that, and, similarly, I've had useful discussions in the last week with organisations like the Royal College of Nursing to discuss this, and it's clear to me that informatics must be used more effectively to ensure that all the information that midwives and doctors need is at hand in order to make the right decisions at the right time for mothers and for babies.

Secondly, a point I made was that Cwm Taf has particular issues around its socioeconomic make-up. There are resultant health issues that arise from this, and, whilst this is no excuse, they clearly have an impact on outcomes. But other areas in Wales have the same challenges, and those other areas also have fewer interventions and safer outcomes for mothers and babies. So, it's really important that the Cwm Taf health board draws on these experiences of similar health boards and learns from them so that things can be different moving forward. I very much welcome the assurances that the Minister gave me personally in the Chamber last week around this co-working.

I also want to spend just a little time addressing the report’s findings around governance. The report talks about inadequacies in clinical leadership, no training and no evidence of board-level plans to develop skills or support leaders, a lack of visible accountability, and, what is worse, the provision of false assurances to the board. And, even when unannounced visits to the board raised concerns to which there should have been a response, the characterisation is of lack of action. Moving to the fourth term of reference, it strikes me as incomprehensible that reviews of governance arrangements should be commissioned and then just left on the shelf. Moreover, there was a lack of clinical involvement. Standard systems of data collection, validation and audit were just not in place. There were no leadership expectations for these functions, so they became nobody’s business.

I want to briefly touch on the last point of the Plaid motion, and explain why I believe that it is the wrong approach. When the Minister gave his statement last week, he outlined a range of interventions to make things right. His focus on establishing an independent maternity oversight panel, strengthening board leadership and providing external scrutiny and support is, to my mind, the correct approach, and I expect that this should lead to a resolution of the challenges in governance systems that I've just described—governance systems that can have such a devastating effect on the lives of people accessing the services.

Similarly, in response to the concerns I raised after his statement, I welcome the Minister's comments around better use of technology to provide greater robustness and certainty about record transfer. Let us not forget, it is only thanks to the Minister's intervention that a light has been shone on these issues. So, instead of scapegoating or looking for an easy headline, let's focus on making things right for the people who rely on these services, and that includes the staff themselves.