Diolch, Llywydd. I'd like to formally move amendment 39, tabled in my name. This amendment, 39, is in line with recommendation 9 of the Health, Social Care and Sport Committee at Stage 1, which recommended that the Minister makes specific provision for the consequences of non-compliance with the duty of candour—with the duty of honesty, integrity, truth. This was tabled by the previous Plaid Cymru spokesman at Stage 2, and we supported the intentions of the amendment then. Stakeholders were very clear that legislation alone will not change the culture of the NHS. This is what this Bill is all about—changing that culture, underpinning it, driving it forward. So, it's imperative there's a mechanism within the legislation to change that at the very top of our NHS bodies.

Going back to the failings we saw at Cwm Taf's maternity services, there was a culture of secrecy, with horrific reports of failings being ignored by senior management. It's a culture shift we need, from the very top, which is what the Minister's aiming for, and I completely support him in that drive. But that's why the duty of candour must have teeth. People have got to know that, if they can't be bothered, if they choose to lie, or if they choose to be evasive, or if they choose to just be in complete denial, or they choose not to act on something, then they will be found out, and they will have to answer for it: end of the conversation. I am brought back to the evidence submitted by board of the CHCs, in which they said the duty must include recognising the key role organisational leaders have in setting the right tone and acting swiftly and decisively when things go wrong. And the Welsh Government will need to give sufficient attention to leadership development and the responsibility and accountability of senior managers in the NHS.

The NHS Confederation—they are the representative body for these health boards, but they said that the absence of any sanctions suggested the new duty of candour may achieve little over and above the duties that NHS Wales organisations and healthcare professionals are already subject to. Let me just say that again: that was the NHS Confederation, and they said that. So, that is sort of the poacher turned gamekeeper, or the other way around—I mean, if they say it, we should listen to it.

I disagree with the Minister's protestations at Stage 2 when he said,

'taking a punitive approach to try to change culture and behaviour, where you want more openness and transparency, is unlikely to achieve all the results that we would all want to see.'

And, actually, I think it's because there has been no clarity over who's responsibility it is for failings that, to be frank, buck passing has become absolutely routine in the Welsh NHS, and ignorance should not be a defence.

We would support amendments 73 and 74, tabled in the name of Rhun ap Iorwerth, as I can see the compromise struck here, and I agree with the sentiment behind reporting serious breaches to Ministers and to the Assembly. We're approaching this from a slightly different angle, but both Plaid Cymru and the Welsh Conservatives want to achieve the same aim here. I would be grateful, though, if the Member would detail what constitutes a serious breach under the amendments, just in the discussion. So, is that an adverse patient outcome, or a systemic failing like we saw at Cwm Taf?