Thank you, Llywydd. Last week, I published the first of three thematic reports setting out the emerging learning from the clinical review programme established by the independent maternity services oversight panel that I appointed. The programme is currently focused on reviewing around 160 episodes of care provided by the maternity and neonatal services of the former Cwm Taf University Health Board between 1 January 2016 and 30 September 2018. The first report focused on the care provided to mothers and specifically those who needed urgent care, which in the main resulted in an admission to intensive care.

As Members will have seen last week, overall the report's findings concur with those of the independent review that I commissioned by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives in 2018. It did not make for good reading when the findings confirmed that, in 27 out of the 28 pregnancies reviewed, factors were identified that contributed to the quality of care that women received. It is a significant concern that, in 19 of the reviews, factors were considered to be major. That means that different care may reasonably be expected to have altered the outcome.

I do not underestimate how distressing this report will have been for the women and their families who have been affected. While I hope it has provided answers to concerns they may have had, the report confirms that those concerns were very real. I remain very sorry for what went wrong and I know that nothing can change what happened for these women and their families. While it is important to be transparent about these findings, I also appreciate that it may well have caused further distress for those affected. It may have triggered those memories of their poor and, at times, traumatic experiences.

The report stresses the importance of listening to women when they know that something is not right. Poor communication is a key theme that underpins the factors identified in the report. I was pleased, however, that the panel recognised the open and compassionate way that the health board has responded and the support that it has put in place for women and families through this review process. I'd also like to thank the community health council advocacy service for the important role that they are playing in this work.

We should not underestimate how difficult this report will have been for staff and particularly at a time when the NHS, including maternity and neonatal services, has been under immense pressure. It is important to acknowledge, as the report does, that considerable improvements have been achieved over the past two years and which the panel has confirmed in its previous reports. This is very much down to the commitment and hard work of the staff and, indeed, the renewed leadership. The thematic report also confirms that those areas of improvement were the right ones to be focused on. 

Last week, I met with Mick Giannasi, who is the chair of the independent panel, and the health board chair, Marcus Longley, to review progress and consider the next steps. The panel will now be turning its attention to completing the reviews of the care of babies who were sadly stillborn. Once individual findings have been shared with women and families, they will produce a further report describing the thematic learning. Their oversight of the maternity aspects of the improvement programme will continue.

In tandem, the panel is increasing its focus on the neonatal aspects of care. The reviews of babies who needed specialist care or sadly died after birth are under way. This is the largest category, involving around 70 reviews. The panel needs to ensure that the immediate learning that emerges from these reviews is aligned to the neonatal aspects of the health board’s improvement programme. This is essential to determine if all required actions have already been addressed or are in progress. 

To ensure that this is as robust as possible, the panel has identified the need to enhance its membership to include neonatal expertise. They have recommended to me that a neonatologist and a neonatal nurse join the panel. In doing so, they propose to draw on the expertise that is already part of the clinical review programme. This will enable them to ensure that the same level of rigour is applied to providing assurance on the neonatal aspects of improvement, in tandem with the learning emerging from the individual clinical reviews.

In order to take stock, they propose to undertake a deep dive of the current service, and to ensure that any improvements needed are being addressed, and are fully picking up the recommendations identified in the royal colleges' review. I was pleased that Marcus Longley, as the chair, confirmed that the board would welcome this development, and the added level of external, independent oversight and advice that it will provide them. This will ensure that they can be fully assured with regard to the quality of neonatal care, and the improvements that they are making.

Women and families remain at the heart of this process. I hope that they can see that I, the independent panel and the health board are determined that we should leave no stone unturned in ensuring that we learn from the past. This, too, is equally important for our staff, as they deserve to work in an open, learning and supportive environment at all times.

I will, of course, continue to keep Members updated, and will issue a further statement once the additional panel members have been confirmed. Thank you.