We have to be careful in suggesting that significant progress has been made, because reading the latest update shows that there are still significant concerns, and, in many ways, at a pretty fundamental level. I'll refer to several elements of the report:

'More than two-thirds...of the actions in the Maternity Improvement Plan are still work in progress';

'still significant work to do in order to meet the performance standards achieved in other Health Boards'; a lack of

'clear milestones, targets and deliverables';

'still a long way to go to improve critical business systems and process like those for handling complaints and concerns'— it's a pretty long list—

'gaps in capability in critical areas like performance analysis, quality improvement and patient engagement'.

I'll sum up some of my key questions, maybe three or four questions. Why are we yet to see the development of the key metrics and milestones that will allow the oversight panel to measure exactly where we are to provide a more evidence-based assessment of progress

'using a richer blend of qualitative and quantitative measures', to quote from the report? I think we need to see ways being developed of measuring much more clearly how far we have come in responding to the scandal.

On staffing levels, a particular question: you state in your statement, very importantly, confirmation that the midwifery staffing levels, you said, which had been given, which the health board had been working to over the past nine months are now in line with Birthrate Plus recommended levels. As I see it from the report, the panel is not able to sign off yet on that, because they still haven't seen the action plan. At the time of writing, not all vacancies had been filled. So, perhaps you could tell us if something has happened over the past three weeks that means that now this threshold has been met, which, actually, it hadn't by the time the report was written.

Could you explain—third question—why you think the panel says it has become increasingly concerned about lack of capacity to deliver improvements? It strikes me that, at this stage, if there are elements that are becoming increasingly concerning, that is something that should be ringing some very, very loud alarm bells indeed, and perhaps should lead to additional intervention to make sure that that issue of capacity in this stage is being addressed.

Finally, why, in relation to complaints, is the culture still apparently so defensive when that has been highlighted as a significant issue? I think we're still hearing of clinical staff saying that they find it difficult to raise complaints. And it's on that whole issue of a culture change needed, I think, that we need to keep a sharp focus still, and that culture change has to be assisted by and taken forward by a framework, I think, for holding NHS managers to account in the way that clinical staff are held to account. We have excellent NHS managers in all parts of the NHS—I met some excellent, innovative managers at Ysbyty Gwynedd last week—but, clearly, you will have poor managers and we need a framework in place to make sure that they are held to account exactly as we would doctors or nurses, who can be struck off if they underperform.

We are talking here as if we need a reminder about something that is as serious an issue as we could ever deal with in our Parliament, the kind of matter, as has been raised here before, that in other countries would have led to the resignation of Ministers, would have led to the disciplining or removal of senior managers. I think we need to remind ourselves that the fact those things have not happened here suggests that some of the most fundamental lessons that should be at the heart of all this have still not been learnt.