It's not just a fair point, but an important one, and part of our challenge about wanting to move away from a punitive culture to a learning one is counter-balancing that with people's demands for accountability, whether at the top, or in the middle, or at the bottom of an organisation as well. So, there's a fear that people will be punished if they stick their head above the parapet—that's part of what led to this being hidden—and it's then about our ability to break through that.

There's also, though—. When you look at the reports from women and families and the way that some had complained about how they were treated, there was a need to actually get into the middle of that prevailing culture amongst some parts of the staff team and to break some of it up. That was difficult because those staff, when they were moved, felt that action was being taken against them and that they were being punished. So, it's not straightforward, but I think that the nurse director in particular has stepped in to do the right thing, in terms of changing some of the rota patterns and in the leadership on values and behaviour as well.

It definitely involves trade unions, in particular the Royal College of Midwives and Unison as the two largest trade unions, and they're directly engaged with the health board in looking to change and improve some of this. That certainly came through in the staff meetings that I had. It was a significant change, from anger and disappointment and some people not feeling pride in the uniform, to a much, much better outlook from staff themselves. So, some progress made, but more to go.