Thank you, Minister, for this statement, and for your recognition of just how difficult a scenario this has been. Like you, I just want to say to all those families out there how desperately sorry I am—and I'm sure we all are—that this has happened.

I was shocked to read that the independent clinical team actually said that, in most of these cases, they concluded that different treatments could reasonably have resulted in different outcomes for mothers and babies. In only one case would the outcome not have been different. So, Minister, that is an awfully big lesson for the health board to learn, and I wondered if you could outline exactly how we can guarantee that those lessons have indeed been learned.

I remember talking about the scandal at Cwm Taf a couple of years ago, when it first broke, and we were looking at it in the health committee. We looked at all of the various reports that had been pointing to the fact that there was a problem, but again and again and again, the then management team and board had just not recognised those problems, or they hadn't percolated up to them. There were all manner of reasons and excuses, et cetera. One of the things that really came out of those early discussions, which I see that the current report reflects, is that, although this is going well and is going in the right direction, it is a work in progress. There is still work to be done in key areas like culture and behaviours, leadership and communication.

Minister, I remember very strongly that one of the things that came forward was the fact that it wasn't just in maternity services, but actually in the whole Cwm Taf ethos, that there needed to be that step change in their culture—the leadership and the communication throughout. So, can you please talk to us a little bit and explain to us about why you feel confident that those lessons have been learned, that those cultures are still changing? We are two years down. The current report still says that there is a long way to go. Of course, we haven't yet touched on the other cases that were involved in this.

The reason why I'm very keen to understand about the culture throughout the whole of this area is because there are other warning signs that have come through on Cwm Taf. Now, you could say that they are completely unconnected, or are they triggers, are they just pointing us to say that, actually, this is a health board where some of these lessons still haven't been embedded throughout, and that this was a systemic failure? So, warning sign one is that negligence payments went from £4.5 million to £13 million in just one year. That indicates to me that there is a lot going on, and that there payments happening because there are unresolved and slowly resolved issues. So, is that a warning sign? Should we be looking at that?

The other area, of course, is the fact that Cwm Taf has had a very high number of COVID deaths because of hospital transmission. Again, that comes down to training, to communication, to leadership, to management. So, you could say, 'Yes, that's entirely unconnected with the matter at hand', but the point that I am trying to make is: have we broken the systemic issues? Was it really just in maternity, or, as has been discussed in various committee meetings over the last few years, part of a slightly bigger picture? I think that your assurance or your reassurance that that is being tackled and that you feel confident that the chair and the current team are really beginning to make that happen will actually start to answer a lot of the other questions, because talking about the detail of what did and didn't happen and all of the reports, as you said earlier, doesn't make any changes to what's happened.